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Wegovy · Prior authorization

Wegovy prior authorization: how to get approved.

Most plans cover Wegovy only after a prior authorization, and most first denials come from a missing detail, not a real no. Here is what insurers commonly look for, the documentation to bring, and exactly what to do if your request is denied.

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What it is

Plan pre-approval

Your insurer must clear Wegovy before the pharmacy can fill it. Your prescriber submits the request.

Common bar

BMI plus diet and activity

Built around the FDA label: BMI 30+, or 27+ with a weight-related condition, alongside lifestyle change.

If denied

You can appeal

Internal review first, then independent external review. The deadline is on your denial notice.

What prior authorization for Wegovy is

Wegovy (semaglutide 2.4 mg) is FDA-approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI of 30 or higher, or 27 or higher with at least one weight-related condition such as high blood pressure, high cholesterol, or type 2 diabetes. Because it is a higher-cost specialty drug, most plans place it behind prior authorization: your prescriber sends the insurer a request, and the plan checks it against its published coverage policy before the pharmacy can dispense.

Prior authorization is not a judgment on whether you need the medicine. It is a documentation check. The plans that approve fastest are the ones whose request answered every criterion the policy asks for, in order, with proof attached. The plans that deny usually do so because something the policy required was not in the file.

What insurers commonly look for

Each plan publishes its own coverage policy, and the exact rules differ. That said, most Wegovy criteria are built around the FDA label and a few recurring documentation patterns. Expect a policy to ask for some combination of:

  • A qualifying BMI. Most policies mirror the label: an adult BMI of 30 or higher, or 27 or higher with at least one documented weight-related condition. A current, dated BMI in the chart is the anchor of the request.
  • A weight-related condition, if your BMI is 27 to 30. Common examples named on the label include high blood pressure, high cholesterol, or type 2 diabetes. The condition needs to be documented, not just mentioned.
  • Lifestyle change on record. The label pairs the drug with a reduced-calorie diet and increased activity. Many policies want to see that this is part of your plan of care, and some ask for a documented prior weight-management effort.
  • Step therapy, on some plans. A minority of plans ask you to try another option first. If yours does and you have already tried and failed an alternative, that history belongs in the request.
  • Confirmation it is not excluded. Some employer plans carve out weight-loss medications entirely. Worth confirming your specific plan does not before you submit, because that changes the path.

Important: the bullets above are the general pattern, drawn from the FDA label and how coverage policies are typically structured. They are not any one insurer's exact criteria. The numbers, codes, and required forms that actually bind your request live in your plan's own published policy. Read that policy, or have your prescriber pull it, before you submit.

The documentation to bring

Give your prescriber a clean packet and the request goes through faster. A strong Wegovy prior authorization usually includes:

  • A current, dated height, weight, and BMI, plus earlier BMI readings if you have them, to show a pattern.
  • Documentation of any weight-related condition (for example high blood pressure, high cholesterol, or type 2 diabetes), with the diagnosis and supporting values.
  • A note that the medicine is prescribed alongside diet and increased activity, plus any documented prior weight-management attempts.
  • If your plan requires step therapy, the record of the prior therapy you tried and why it did not work.
  • The plan's completed prior authorization form for the medicine, signed by your prescriber.

Care decisions, including whether Wegovy is right for you, stay between you and your prescriber. AppealIt does not provide medical advice.

What to do if your prior authorization is denied

A denied prior authorization is not a final no. Under the Affordable Care Act, you have the right to a full internal appeal with your plan, and if that is upheld, an independent external review by a reviewer outside the insurer. The move that works is precision: get the exact policy the plan applied, then show, point by point, where your records meet each criterion it lists.

  • Read the denial reason. It points to the specific criterion the plan says was not met. That is the thing your appeal has to answer.
  • Map your records to the policy. Answer each criterion in order, with the page of your record that proves it, rather than a general letter.
  • File before the deadline. The window is stated on your denial notice, often between 60 and 180 days. The notice controls, so check it.
  • Escalate if upheld. If the internal appeal is denied, request the independent external review. A reviewer outside the plan takes a fresh look.

See the full walkthrough on our Wegovy denial and appeal guide, or jump straight to a read on your odds.

The magic is visible

If you are appealing, your draft is built from your plan's own rules. Every citation checked.

We draft from the sources below, then verify each one before you file. On our held-out testing: 0 invented citations, versus about 1 in 4 for raw AI.

  • Your plan's coverage policyThe specific prior authorization criteria for anti-obesity agents that apply to your planVerified
  • FDA labelSemaglutide (Wegovy) prescribing information, indication and dosingVerified
  • Your recordsYour BMI history, weight-related conditions, and prior therapies, cited back accuratelyVerified

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Wegovy prior authorization: common questions

What do insurers usually require to approve Wegovy?
Most plans build their criteria around the FDA label: an adult BMI of 30 or higher, or 27 or higher with at least one weight-related condition such as high blood pressure, high cholesterol, or type 2 diabetes, alongside a reduced-calorie diet and increased activity. Some plans add step therapy or a documented prior weight-management effort. The exact rules live in your plan's published policy, so read it before you submit.
How long does a prior authorization take?
Standard pharmacy prior authorization decisions are commonly returned within a few business days once the plan has a complete request, and an expedited review is faster. Timeframes vary by plan, so the turnaround your plan publishes is the one that applies to you.
What if my BMI is between 27 and 30?
The FDA label allows a BMI of 27 or higher when there is at least one weight-related condition. If that is your situation, the request needs documentation of both the BMI and the qualifying condition. Whether the medicine is appropriate for you is a decision for you and your prescriber.
What if my prior authorization is denied?
A denial is not the end. You have the right to an internal appeal with your plan, then an independent external review if that is upheld. The winning move is to map your records to the exact policy criteria the plan cited. We draft that appeal for free, grounded in your plan's own rules with every citation verified. AppealIt is not a law firm and does not provide legal or medical advice.

If you are already denied: All Wegovy denials · Aetna · UnitedHealthcare · Cigna