Wegovy Insurance: Coverage, Cost, and Appeals

Wegovy® (semaglutide) is a prescription medication used for chronic weight management (Wegovy Prescribing Information (PDF)). It’s also approved to reduce the risk of major adverse cardiovascular events (heart attack, stroke, cardiovascular death) in certain adults with established cardiovascular disease and obesity/overweight (see Indications and Usage in the prescribing information).

If you’re searching Wegovy insurance, here’s the direct answer:

• Commercial coverage varies by plan, and prior authorization is common.
• Medicare Part D generally excludes drugs when used for weight loss (but may cover for other FDA-approved uses).
• Self-pay is often expensive, though official cash-price and savings options may help.

This guide walks you through the workflow—formulary check → prior authorization → appeal → savings/self-pay options—so you can verify coverage and estimate what you’ll pay.

This article is informational only and is not medical advice. Wegovy is a prescription medication—talk with a qualified clinician before starting, stopping, or changing any medication. For plan-specific coverage decisions, contact your insurer or your pharmacy benefit manager (PBM—the company that often administers your prescription drug benefit, including the formulary and prior authorization rules).

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TL;DR

• Many plans require prior authorization; NovoCare’s coverage workflow notes PA is required by most plans (NovoCare Wegovy coverage check).
• With commercial insurance, eligible patients may reduce their copay and pay as little as $25/month using a manufacturer savings offer (commercial plans only; not for government programs; limits/terms apply and can change—see current details) (Wegovy savings offer).
• If you’re self-pay/uninsured, the official Wegovy cost page lists reduced cash-price pathways and time-limited intro offers (terms can change) (Wegovy cost & coverage).

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A practical “cost estimator” you can do in 5 minutes (no tool needed)

If you want a quick, realistic monthly estimate, gather these inputs first:

1. Insurance type: commercial vs Medicare Part D vs no insurance
2. Formulary status: covered vs excluded vs unknown
3. Restrictions: prior authorization (PA) / step therapy / quantity limits
4. Your current benefit stage: deductible not met vs met (or coinsurance)
5. Savings eligibility: manufacturer savings offers typically exclude government-funded programs (check the offer terms)

Example scenarios (illustrative)

These are illustrations to help you sanity-check what you’re told on the phone—your plan rules win.

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How Wegovy insurance coverage works (why it feels inconsistent)

Most Wegovy insurance outcomes come down to three factors:

1. Formulary status: Is Wegovy on your plan’s drug list—and at what tier?
2. Utilization management (UM): rules insurers use to control access and cost—like prior authorization, step therapy, and quantity limits
3. Use/indication rules: Is the prescription aligned with what your plan considers covered for that drug?

Even when plans cover glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) weight-loss medications, restrictions are common.

In a GoodRx analysis published January 2026, “restricted coverage” was defined as requiring additional steps such as prior authorization or step therapy; the report notes that among commercially insured people with coverage for weight-loss GLP-1/GIP medications, over 88% faced these additional requirements (GoodRx: insurance coverage requirements for weight-loss GLP-1s).

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Step 1: Check if Wegovy is covered (fastest path)

1) Check your plan formulary (the “source of truth”)

Look up your prescription drug formulary (pharmacy benefit), then search:

• Wegovy
• Notes such as PA required, step therapy, quantity limits
• The tier (tiers drive copays/coinsurance)

If your plan is employer-sponsored, two people with “the same insurer” can have totally different drug coverage because employers can choose different formularies and exclusions.

2) Confirm restrictions (PA and step therapy)

If your plan says “PA required” or “step therapy,” ask for the written criteria (some plans/PBMs will email or portal-message it). Then share it with your prescriber’s office so they can submit the right documentation the first time.

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Step 2: Prepare for prior authorization (PA)

Think of PA as an “evidence packet” your clinician submits to show you meet plan criteria.

What to ask your insurer/PBM for (verbatim):

• “What are the PA criteria for Wegovy, and can you send them to me?”
• “Is step therapy required? If yes, what counts as completion?”
• “What documentation is required (clinic notes, labs, prior meds)?”
• “What’s the expected turnaround time?”

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Commercial insurance: how to get Wegovy covered (and lower your monthly cost)

What “covered” can mean

Commercial coverage can look like:

• A low copay
• A higher copay
• Coinsurance
• “Covered after deductible” (often the surprise)

If you qualify for the manufacturer copay savings offer, the headline number advertised is as little as $25 per month, but savings limits and eligibility rules apply and the offer terms can change.

Commercial coverage checklist

1. Screenshot your formulary listing (tier + restrictions).
2. Ask your prescriber’s office if they can submit PA electronically.
3. Confirm your preferred pharmacy channel (retail vs mail order).
4. If approved and eligible, ask the pharmacy to apply the manufacturer savings offer.

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Medicare Part D: when Wegovy may be covered (and why it may still be pricey)

The baseline rule: Part D excludes drugs “when used for weight loss”

CMS’ Part D guidance lists “agents when used for anorexia, weight loss, or weight gain” as not covered under the basic Part D benefit (CMS Part D excluded drugs PDF).

The practical exception: coverage can exist for other FDA-approved uses

If a drug has an FDA-approved use that isn’t “weight loss,” Part D coverage may be possible depending on plan design and rules. The Wegovy prescribing information summary page lists use for reducing major cardiovascular events in certain adults with established cardiovascular disease and obesity/overweight (Wegovy prescribing information summary).

Medicare out-of-pocket costs: why it can still be expensive

Here’s the key mechanic: copay means a flat dollar amount; coinsurance means you pay a percentage of the drug’s cost.

KFF estimates that beneficiaries using Wegovy under the cardiovascular indication could face $325–$430 per month out of pocket in some scenarios (KFF Medicare coverage analysis). Their estimate is based on a list price around $1,300/month and typical Part D coinsurance designs.

Part D out-of-pocket protections (2024 vs 2025)

• In 2024, CMS explains that once a beneficiary reaches catastrophic coverage, they pay $0 for covered Part D drugs for the rest of the year; CMS examples show total out-of-pocket contributions often around $3,300–$3,800 depending on brand/generic mix (CMS 2024–2025 Part D OOP explainer (PDF)).
• In 2025, the standard Part D benefit design includes a $2,000 annual out-of-pocket threshold (CMS CY 2025 Part D redesign fact sheet).

Medicare policy and plan formularies can change; always verify your current-year Part D plan documents.

Quick Medicaid note (because “insurance” searches often include it)

Medicaid outpatient prescription drug coverage is administered at the state level, and coverage/management rules can differ by state and plan. Medicaid.gov provides state prescription drug program resources that can help you find your state’s approach (Medicaid state prescription drug resources).

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Self-pay / uninsured: how to lower the cash price (legit options)

Know the baseline “sticker price” range

Different sources may describe price differently (for example, list/benchmark pricing vs typical retail cash). One benchmark term you may see is wholesale acquisition cost (WAC)—a drug list price that does not include discounts, reductions, or rebates (HHS ASPE uses WAC as a list-price measure in drug price tracking) (HHS ASPE drug price tracking brief (PDF)).

For context:

• The official Wegovy cost page discusses out-of-pocket costs and then lists lower-price pathways for eligible people (Wegovy cost & coverage).
• GoodRx summarizes a list price of about $1,350 for a 28-day supply (GoodRx cost & coverage overview).

Safety note: avoid counterfeit or unapproved GLP-1 products

If cost pressure pushes you toward “too-good-to-be-true” options, pause. The FDA has raised concerns about unapproved GLP-1 drugs (including semaglutide products sold online or represented as compounded) and notes issues such as fraudulent labeling, dosing errors, and use of unapproved semaglutide salt forms (FDA: concerns with unapproved GLP-1 drugs used for weight loss).

What to look for on the official Wegovy cost page

On the official “what to pay” page, look specifically for:

• Commercial insurance: language about paying as little as $25/month (if eligible)
• Self-pay/uninsured: reduced cash-price pathways and time-limited intro offers
• Home delivery: references to NovoCare Pharmacy delivery

Because offers can change, confirm the current terms on the official page the same day you’re trying to purchase.

A simple self-pay strategy

1. Check the current manufacturer cash-price pathway on the official site.
2. Compare against reputable coupon/discount tools (GoodRx summarizes discount paths and pricing) (GoodRx cost & coverage overview).
3. Ask the pharmacy what the cash price is before you fill.

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Wegovy coverage verification workflow

Use this as a simple checklist to verify coverage—without guessing which insurer “covers it.”

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Toolkit: call scripts + PA + appeal templates (copy/paste)

Templates below are educational starting points—follow your plan’s instructions and your clinician’s documentation guidance.

1) Patient call script (insurer / PBM)

Goal: confirm coverage, requirements, and your expected cost.

Hi—can you help me check coverage for Wegovy (semaglutide) under my pharmacy benefit?

1. Is Wegovy on my formulary? What tier?
2. Do you require prior authorization or step therapy?
3. Are there quantity limits?
4. Is mail order required or preferred?
5. What is my estimated out-of-pocket cost today (before and after deductible)?
6. If denied, what is the appeal process and timeline?

2) Prior authorization “cover note” (for your prescriber to adapt)

Patient: [Name], DOB: [DOB]

Medication requested: Wegovy (semaglutide)

Indication: [FDA-approved indication that applies]

Clinical summary: [Plan criteria—BMI/diagnosis], relevant comorbidities, prior therapies/attempts, and rationale for requesting Wegovy.

Requested outcome: approval per plan criteria.

3) Appeal letter template (patient-facing)

Opening

Date: [MM/DD/YYYY]

To: [Insurance Plan Name] Appeals Department

Re: Appeal for coverage of Wegovy (semaglutide)

Member ID: [ID]

I am writing to appeal the denial of coverage for Wegovy (semaglutide).

Why you’re appealing

My clinician prescribed this medication and believes it is medically appropriate based on my health history and the plan’s criteria.

Attachments

Please review the attached:

• Denial letter
• Supporting clinical documentation from my prescriber
• Relevant formulary/PA criteria (if available)

Request + contact

I request that the plan overturn the denial and approve coverage.

If additional information is required, please contact me at [phone/email] and my prescriber at [clinic contact].

Sincerely,
[Name]
[Phone]

4) HR / benefits request template (employer-sponsored plans)

Subject: Request to Add/Expand Wegovy Coverage in Our Pharmacy Benefit

Hi [Benefits Team/HR Name],

I’m requesting that our health plan consider adding coverage (or improving access) for Wegovy (semaglutide), an FDA-approved prescription medication.

If available, I’d appreciate details on:

• Whether weight management medications are included in our pharmacy benefit
• Whether Wegovy is excluded or restricted
• The process and timeline for formulary review

Thank you for your help,
[Name]

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FAQ: Wegovy insurance

Is Wegovy covered by insurance?

Sometimes. Coverage is plan-specific: many commercial plans cover it with restrictions (like prior authorization), while some plans exclude weight-loss medications entirely. The fastest way to confirm is to check your prescription formulary and then call your insurer/PBM to ask what requirements apply.

How do I check if my insurance covers Wegovy?

Start with your plan’s online formulary search for “Wegovy.” Then call the number on your prescription card and ask about tier, prior authorization/step therapy, and your estimated cost (before/after deductible).

If you want a guided check, NovoCare offers a coverage lookup tool: NovoCare Wegovy coverage check.

Does Wegovy require prior authorization?

Often, yes. In many plans, weight-loss GLP-1 medications have prior authorization or step therapy requirements (GoodRx: insurance coverage requirements for weight-loss GLP-1s).

Can Medicare Part D cover Wegovy for weight loss?

Under the basic Part D benefit, drugs used for weight loss are generally excluded. Coverage may still be possible for non-weight-loss indications, depending on plan rules.

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How BodySpec fits in: track fat loss vs muscle loss (not just scale weight)

Insurance access is one half of the story. The other half is making sure the weight you lose is the kind you want to lose.

A scale can’t reliably distinguish fat from lean mass. A DEXA body composition scan can help estimate fat mass and lean mass separately—especially when you keep prep consistent and track trends over time (see DEXA scan accuracy: understanding the gold standard).

Helpful next reads:

• Wegovy dosing chart and weekly schedule
• Wegovy muscle loss: causes & prevention strategies
• Side effects of Wegovy: common risks & management
• DEXA scan for visceral fat: accuracy, cost & results
• Prepare for your BodySpec scan

Ready to measure progress? You can book a BodySpec DEXA scan.

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Your 10-minute action plan

1. Search your plan formulary for Wegovy and note tier + restrictions.
2. Confirm whether PA/step therapy is required—and request the criteria document.
3. If PA is required, send your prescriber the PA “cover note” template.
4. If denied, file an appeal and ask your prescriber to submit supporting documentation.
5. If coverage isn’t available, compare official cash-price pathways and reputable discount tools—and keep your progress measurable with body composition tracking.