Wegovy Prior Authorization: Complete Patient Guide

Why Is Wegovy Coverage So Much Harder Than Ozempic?

The same active drug (semaglutide) in Ozempic approves at 70-90% but Wegovy approves at only 20-40%. Why the difference?

• Indication bias: Diabetes is universally recognized as a medical disease requiring treatment. Weight loss feels less "medical" to insurance companies, even though obesity is now recognized by AMA and WHO as a disease with cardiovascular, metabolic, and quality-of-life consequences.
• Cost concern: Wegovy costs $1,500+/month. For a drug used primarily for weight loss (not survival), insurers are more conservative about authorizing ongoing costs. Ozempic, used for diabetes management, feels more "necessary."
• Newer medication: Wegovy was FDA-approved in 2021 — very recent in insurance timescales. Many older insurance formularies are still being updated. Ozempic came out in 2017; policy has had more time to develop.
• Step therapy resistance: Many insurers want to see you fail on cheaper weight loss options (orlistat, phentermine, behavioral programs) first. There's less pushback on step therapy for diabetes because there is clear step therapy (metformin > sulfonylurea > GLP-1).
• Stigma: Regrettably, some insurance medical directors still view weight loss medications skeptically, as if patients could "just try harder" with diet. This bias does not exist for diabetes medications.

Understanding this context is important: Wegovy denial is not a reflection of whether it's right for you. It's a reflection of insurance company conservatism. Successful appeals typically involve educating the insurance company about the medical evidence.

BMI and Eligibility: What Your Insurance Requires

Before even submitting a PA, you need to meet your insurance company's BMI threshold. These vary significantly:

How to Calculate Your BMI

BMI = (weight in pounds × 703) / (height in inches)²

Example: 200 lbs, 5'6" (66 inches)
BMI = (200 × 703) / (66²) = 140,600 / 4,356 = 32.3

Most insurance companies use the weight and height in your medical records, not your self-reported numbers. Ask your prescriber to confirm what weight/height are documented in your chart — that's what insurance will verify against.

Weight-Related Comorbidities That Reduce BMI Threshold

If your BMI is 27-30 (just below the standard 30 threshold), you may still qualify if you have a documented comorbidity. Insurance companies recognize these as weight-related:

• Type 2 diabetes
• Hypertension (blood pressure > 140/90)
• Coronary artery disease or history of MI/stroke
• Obstructive sleep apnea (diagnosed by sleep study)
• Nonalcoholic fatty liver disease (NAFLD)
• Osteoarthritis affecting weight-bearing joints
• GERD (if weight-related)
• Dyslipidemia (elevated cholesterol/triglycerides)

Make sure your medical records document these diagnoses. If you have a comorbidity but it's not in your chart, ask your prescriber to document it before submitting PA.

What Your Prescriber Must Submit

Documentation Checklist

Before your prescriber submits the PA, confirm they are including:

• ☐ Current weight and height in the medical record (verifiable, not self-reported)
• ☐ Calculated BMI matching insurance's requirement (≥ 30 or ≥ 27 with comorbidity)
• ☐ Diagnosis codes: overweight (E66.9) or obesity (E66.01/E66.02/E66.09)
• ☐ List of failed weight loss attempts: at minimum 2-3 attempts with details (program name, duration, approximate weight change)
• ☐ Documentation that behavioral interventions were attempted (dieting, exercise, or counseling) with duration and outcome
• ☐ Documentation of weight-related comorbidities (diabetes, hypertension, sleep apnea, etc.) if BMI is 27-29
• ☐ Clinical justification: "GLP-1 agonist indicated for chronic weight management given documented obesity and [comorbidities]"
• ☐ Confirmation: not pregnant, no personal/family history of medullary thyroid cancer, no contraindications
• ☐ Prescriber's statement that benefits of Wegovy outweigh risks for this patient

How to Document Failed Weight Loss Attempts

Insurance wants evidence you've tried and failed. This is often the key missing piece in denied PAs. You don't need clinical trial data — common weight loss attempts count:

• Weight Watchers: "Participated in WW for 4 months (2024-01-15 to 2024-05-15). Initial weight 225 lbs, final weight 220 lbs (5 lb loss). Regained 10 lbs by end of 2024."
• Personal trainer or gym: "Joined gym and worked with personal trainer March 2024 - June 2024 (3 months). No sustained weight loss despite consistent exercise 4x/week."
• Nutritionist counseling: "Consulted with registered dietitian 6 times from Feb-April 2024. Attempted calorie restriction (1,800 cal/day target). Weight remained stable 210-215 lbs."
• Prior medications: "Tried phentermine October 2023 - December 2023. Minimal appetite suppression; weight unchanged."
• Self-directed dieting: "Attempted low-carb diet January 2023 - June 2023. Lost 8 lbs initially, then regained 12 lbs."

Key insight: If you've tried these things informally and don't have formal documentation, ask your prescriber to document it in the chart based on your description. Even informal attempts with details count more than no documentation at all.

Common Wegovy Denial Reasons and Appeal Strategies

Denial 1: "Weight Loss Is Cosmetic, Not Medical Necessity"

What this means: Insurance company argues that losing weight is a cosmetic goal, not medically necessary. "Patient wants to look better, not treat a disease."

This is wrong. Obesity is classified by AMA and WHO as a chronic disease. Weight loss in obese patients is medical treatment, not cosmetic. Here's how to appeal:

Appeal strategy: Your prescriber should cite clinical evidence:

• "Obesity is classified as a chronic disease by the American Medical Association (resolution passed 2013). Weight loss is medical treatment, not cosmetic."
• "Patient's obesity is associated with [list comorbidities: diabetes, hypertension, sleep apnea]. Weight loss improves these conditions and reduces all-cause mortality."
• "Semaglutide (Wegovy) demonstrated 20% reduction in major adverse cardiovascular events in the SELECT trial (NEJM 2023). This is not cosmetic — it's life-saving."
• "Denying coverage for evidence-based weight loss medication while covering expensive diabetes and hypertension drugs used to treat consequences of obesity is medically contradictory."

Success rate: ~40-50% of cosmetic denials are reversed on appeal, especially with peer-to-peer review.

Denial 2: "Insufficient Documentation of Failed Weight Loss Attempts"

What this means: Insurance acknowledges obesity but says you haven't adequately tried behavioral approaches first.

Appeal strategy: Submit detailed documentation of weight loss attempts, including:

• Names and dates of diets/programs tried
• Duration (months/years, not just "tried once")
• Approximate weight loss achieved and weight regain after stopping
• If available: visits to registered dietitian or weight loss clinic
• If applicable: failed trials of other weight loss medications (phentermine, orlistat, topiramate)

If you don't have formal documentation, ask your prescriber to document your description in your chart: "Patient reports multiple failed attempts at weight loss via diet and exercise including [specific attempts]. Despite reasonable efforts, sustained weight loss unachieved without pharmacotherapy."

Denial 3: "BMI Doesn't Meet Criteria"

What this means: Your BMI is below the insurance company's threshold (e.g., BMI 28.5 and they require ≥ 30).

Appeal strategy:

• Verify the weight/height used: Insurance uses medical record data, not your current weight. If you've gained weight since your last visit, your prescriber should document current weight at next visit and resubmit.
• Identify qualifying comorbidities: If you have diabetes, hypertension, or sleep apnea and BMI ≥ 27, you may qualify under the lower threshold. Make sure your prescriber documented this in the chart.
• Request plan criteria clarification: Some insurance plans allow BMI ≥ 27 with comorbidity even though their standard policy says ≥ 30. Ask your prescriber to request explicit criteria for your specific plan.

Denial 4: "Patient Must Try Orlistat or Phentermine First"

What this means: Insurance uses step therapy, requiring cheaper/older weight loss drugs before approving expensive Wegovy.

Appeal strategy: Your prescriber can argue:

• "Phentermine is recommended for short-term (≤12 weeks) use only and is not appropriate for the chronic weight management this patient requires."
• "Orlistat has poor efficacy (average 3-5 lbs weight loss over 6 months) and is inferior to GLP-1 agonists in both efficacy and cardiovascular benefit."
• "Step therapy to inferior agents is not standard of care. ADA/AMA guidelines recommend GLP-1 agonists as first-line pharmacotherapy for chronic weight management in eligible patients."

Practical option: If insurance really won't budge on step therapy, your prescriber can trial phentermine for 6-8 weeks (document lack of adequate response), then resubmit PA for Wegovy with "failed step therapy" documentation. This takes more time but often succeeds.

Denial 5: "Medically Necessary but Not Cost-Effective"

What this means: Insurance admits Wegovy is medically appropriate but refuses to cover it due to cost.

Appeal strategy: This is tougher but cite long-term cost savings:

• "Long-term GLP-1 therapy reduces obesity-related comorbidities (diabetes, heart disease, joint disease) requiring expensive ongoing treatment. Upfront Wegovy cost is offset by downstream medical cost reduction."
• "SELECT trial showed 20% reduction in MACE at $1,500/month cost. Cost per life-year saved is well under typical insurance thresholds."

Honest assessment: Cost-based denials are hardest to overcome because insurance companies prioritize budget over individual cases. Peer-to-peer review sometimes helps. If this fails, external appeals (see section below) are your option.

Insurance Company–Specific Wegovy PA Patterns

Aetna

PA requirement: BMI ≥ 30 (or ≥ 27 with comorbidity), documented failed weight loss attempt, no prior GLP-1 for weight loss (step therapy to other agents varies).

Approval rate: ~50-60% — among the most permissive.

Denial patterns: Denials often cite insufficient failed attempt documentation. Submit detailed attempt history upfront.

Appeal success: ~70% of Aetna denials reverse on appeal with comprehensive documentation.

Cigna

PA requirement: BMI ≥ 30 (or ≥ 27 with comorbidity), documented weight loss attempts, comorbidity documentation preferred.

Approval rate: ~40-50%.

Denial patterns: Mix of BMI threshold and failed attempts. Varies by region.

Appeal success: ~60% on appeal.

UnitedHealthcare (UHC)

PA requirement: BMI ≥ 30, documented weight loss attempts, often requires step therapy (phentermine or orlistat trial first in many plans).

Approval rate: ~30-40% — more restrictive.

Denial patterns: High rate of "step therapy required" denials. Some regional UHC plans have no Wegovy coverage at all.

Appeal success: ~50% on appeal, especially with peer-to-peer.

Blue Cross/Blue Shield (BCBS)

PA requirement: Highly variable by state and specific plan.

Approval rate: ~35-50% (varies dramatically by state).

Your move: Have your prescriber check your specific BCBS plan upfront. Coverage varies wildly by state and sub-plan.

Humana

PA requirement: Generally stricter than others. BMI ≥ 30 usually required, often with step therapy to older agents.

Approval rate: ~25-35% — most conservative of major insurers.

Appeal success: ~40% on standard appeal. Peer-to-peer improves to ~60%.

Medicare

Coverage: Medicare does not currently cover Wegovy, even for eligible beneficiaries with obesity and comorbidities. This is a major gap in Medicare policy (as of February 2026) and is a subject of ongoing advocacy. Some Medicare Advantage plans (private plans within Medicare system) may cover Wegovy — check your specific MA plan.

Peer-to-Peer Reviews: Your Secret Weapon for Wegovy

Peer-to-peer reviews are especially powerful for Wegovy denials because they allow your prescriber to educate the insurance medical director about obesity as a disease and about the clinical evidence for GLP-1 agonists.

Why Peer-to-Peer Works

Written appeals go to non-physician reviewers who apply formulary rules mechanically. Peer-to-peer means your prescriber (usually an MD/DO) talks directly to the insurance company's medical director (also an MD/DO). Doctor-to-doctor conversation has many advantages:

• Education: Your prescriber can explain that obesity is a disease (AMA classification), not a moral failing.
• Evidence discussion: Physician-to-physician, they can discuss SELECT trial data showing Wegovy's cardiovascular benefit.
• Bias interruption: The insurance medical director may have outdated views about weight loss. Another physician can respectfully challenge this.
• Nuance: Physician can explain your specific situation — "This patient has sleep apnea and hypertension; weight loss will improve both."
• Authority: Prescriber has clinical authority that the insurance company's non-physician reviewer may not have.

Peer-to-Peer Success Rates

• Standard appeal success: ~50% of written appeals overturn initial denials.
• Peer-to-peer success: ~70-75% of peer-to-peer reviews result in approval (even if initial denial).

How to Request a Peer-to-Peer Review

Step 1: After initial denial, call your insurance company's PA department and ask: "My prescriber would like to request a peer-to-peer review with the medical director."

Step 2: Insurance company schedules the call (usually within 24-72 hours).

Step 3: Your prescriber's office participates in the call. Make sure they have your full medical chart available and have time to speak thoughtfully (not rushed).

Step 4: After the call, insurance company issues a new determination (often approval).

What your prescriber should be prepared to discuss:

• "Obesity is a chronic disease per AMA, WHO, and American Heart Association. Treatment with evidence-based medications is standard of care."
• "SELECT trial (published NEJM 2023) showed semaglutide reduces major adverse cardiovascular events by 20% — this is not cosmetic, this is life-saving."
• "GLP-1 agonists are recommended by ADA/AMA/ASPC for weight management in eligible candidates."
• "This patient specifically: [list comorbidities]. Weight loss will improve these conditions."

Timeline and What to Do While Waiting

Expected Timelines

How to Start Treatment While Waiting

• Use the copay card: Novo Nordisk's savings card reduces copay to $25/month (commercial insurance) or $0-50 (uninsured). This works even while PA is pending.
• Ask for samples: Some prescribers have starter samples (0.25mg or 0.5mg pens). Ask if you can start on samples while PA processes.
• Consider GLP-1 alternatives if approved: If your insurance denies Wegovy but approves other GLP-1 agonists (like Ozempic or Mounjaro), you might start on those while appealing Wegovy. Some patients later switch to Wegovy once insurance relationships improve.

Crafting an Effective Wegovy Appeal Letter

Key principles for Wegovy appeals:

• Emphasize disease: Wegovy appeals must emphasize obesity is a chronic disease, not a cosmetic issue. Use official classifications (AMA, WHO).
• Document failed attempts: Be specific about what you tried and for how long. Vague statements don't work.
• Cite evidence: Reference SELECT trial and ADA/AMA guidelines. Insurance medical directors know these guidelines and respect them.
• Address comorbidities: Highlight weight-related conditions (diabetes, hypertension, sleep apnea) that will improve with weight loss.
• Offer peer-to-peer: Indicate your prescriber is available for physician-to-physician discussion. This often leads to approval.

External (Independent) Appeals: When Internal Appeals Fail

If your insurance company denies both the initial PA and your internal appeals, you have the right to request an external independent review. An independent review organization (IRO) — not affiliated with your insurance company — reviews your case.

Advantages of External Appeal

• Independent judgment: Reviewed by physicians not employed by insurance company, removing conflict of interest.
• Higher success rate: External reviews approve ~60% of cases that insurance denied, particularly when there's clinical basis for treatment.
• It's free: You don't pay for external review; insurance company pays.

How to Request External Appeal

Step 1: After insurance denies your internal appeal, request the external review right in your denial letter. It typically says something like: "You have the right to request an independent external review. Contact [phone/email]."

Step 2: Call or email within 60 days of denial. Say: "I request an independent external review of the Wegovy prior authorization denial for [patient name], Member ID [XXX]."

Step 3: Insurance company forwards your case to an independent review organization (often RESOLVE, CarePoint, or similar).

Step 4: You and your prescriber can submit additional documentation to the IRO (typically have 5-10 days).

Step 5: IRO reviews and makes determination (typically within 14-30 days).

Step 6: IRO's decision is binding on the insurance company.

What to Submit to External Review

• Your complete medical records (especially weight loss attempt history and comorbidities)
• Your prescriber's clinical justification for Wegovy
• Copies of your appeal letters
• Any additional evidence of failed weight loss attempts (gym receipts, diet program records, etc.)
• Documentation of comorbidities (lab results, diagnoses, medication list)

Cost Strategies If Insurance Won't Cover

If all appeals fail and insurance remains unwilling to cover Wegovy, explore these options:

Use the Copay Card Long-Term

Novo Nordisk's copay card reduces the cost to $25/month (commercial insurance) or up to $0 (uninsured/low-income). While this is out-of-pocket, it's substantially cheaper than the $1,500/month list price.

Novo Nordisk Patient Assistance Program

If uninsured/underinsured and meet income criteria, Novo Nordisk has a full patient assistance program providing Wegovy at no cost. Visit novonordisksavings.com or call 1-855-NOVO-COP (1-855-686-8267) for eligibility.

Clinical Trials

Some clinical trials testing obesity treatments offer free medication to participants. ClinicalTrials.gov allows you to search for Wegovy trials in your area.

Consider Different GLP-1 If Approved

If insurance approves a different GLP-1 agonist (Ozempic for weight loss, Mounjaro, older GLP-1s) but not Wegovy, you might start with the approved option while continuing to appeal Wegovy. Some patients use this as a stepping stone.

Key Takeaways for Wegovy PA Success

• Expect denial initially. Wegovy has high initial denial rates (60-80%), but most are reversed on appeal. Denial is not final.
• Document failed weight loss attempts meticulously. This is often the difference between approval and denial. Be specific about programs tried and durations.
• Emphasize obesity as a disease. Use official classifications (AMA, WHO) in your appeal. This reframes the conversation from "cosmetic" to "medical."
• Request peer-to-peer reviews. These have ~70% success vs. ~50% for written appeals. Your prescriber talking to insurance's medical director is powerful.
• Use the copay card while waiting. Novo Nordisk's $25/month card lets you start treatment even if PA is pending or initially denied.
• Know your insurance company's specific patterns. Aetna and Cigna are generally more permissive; UHC, Humana, and many BCBS plans are stricter. Different strategies work for different insurers.
• External appeal if necessary. If insurance denies both initial PA and internal appeals, external independent review approves ~60% of cases.