Semaglutide, known as Wegovy for chronic weight management, is a glucagon-like peptide-1 (GLP-1) receptor agonist. It works by mimicking an intestinal hormone that targets appetite centers in the brain and slows stomach emptying. While the same active ingredient is sold as Ozempic for Type 2 diabetes, Cigna coverage for the weight loss indication is complex, with no simple “yes” or “no” answer. Coverage is determined by the specific benefit plan purchased, the company’s general formulary policy, and the patient’s documented medical history.
Cigna’s General Policy on Weight Loss Medication
Cigna classifies anti-obesity medications (AOMs), such as Wegovy, as an optional benefit rather than a standard inclusion in all plans. The insurer maintains a national formulary, a list of covered drugs, but this list is subject to the specific exclusions chosen by the plan purchaser. Weight loss medications are frequently listed as a non-covered category under many commercial contracts.
When Wegovy is covered, it is typically categorized as a specialty medication, meaning it will be placed on a higher cost-sharing tier, often Tier 3 or above. This placement translates directly to a higher out-of-pocket expense for the member, even with coverage approval. The inclusion of Wegovy on a formulary universally triggers the requirement for Prior Authorization (PA) before the pharmacy benefit will pay for the prescription.
The Role of Specific Cigna Plan Types
The primary factor determining whether a Cigna member has coverage for semaglutide is the specific contract purchased by their employer or by the individual. Most Cigna members are enrolled in employer-sponsored plans, where the employer has the authority to select which benefits are included. Many employers choose to exclude AOMs by opting out of a “weight management rider” or similar optional benefit package to manage premium costs.
The distinction between plan types is significant because fully insured commercial plans, where Cigna assumes the financial risk, may differ greatly from self-funded plans. Individual and marketplace plans are subject to state-level mandates that can sometimes require coverage for obesity treatment, though these mandates vary widely. Federal programs like Medicare Part D are currently prohibited by law from covering weight loss medications. In every scenario, the specific benefit plan document purchased dictates whether the weight loss drug is covered at all, overriding Cigna’s general policy.
Navigating Prior Authorization and Medical Criteria
Assuming a Cigna plan includes coverage for weight loss medications, the member must satisfy a rigorous Prior Authorization (PA) process to demonstrate medical necessity. The prescription must be written for the FDA-approved weight management indication, meaning the brand name Wegovy must be used, rather than Ozempic. The patient must be at least 18 years of age and must meet specific body mass index (BMI) thresholds.
Cigna’s criteria require the patient to have a BMI of 30 or greater, or a BMI of 27 or greater if they also have at least one weight-related comorbidity. These comorbidities include conditions like Type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea. The PA request must also document that the patient has already attempted a trial of supervised diet and exercise for a defined period, typically three months, without achieving successful weight reduction. This step therapy requirement ensures that less costly treatments have been tried first.
For coverage to continue beyond the initial approval period, the patient must demonstrate a measurable clinical response to the medication. Cigna commonly requires the patient to show a minimum percentage of weight loss from their baseline body weight, such as a 4% or 5% reduction, within the first few months of therapy. The prescribing physician must submit documentation verifying this progress for the re-authorization to be approved. This process requires detailed clinical records and active engagement from the healthcare provider’s office.
What to Do If Coverage is Denied
If a Prior Authorization request is denied, or if the plan excludes coverage for weight loss drugs entirely, the Cigna member has formal recourse through the internal appeals process. Submitting a formal request for an appeal requires the member or their provider to present additional documentation supporting the medical necessity of the treatment. This documentation should specifically address the reasons for the initial denial, such as providing more detailed records of failed supervised weight loss attempts or clarifying the patient’s co-morbid conditions.
If the internal appeal is unsuccessful, the patient may pursue an external review, where an independent review organization assesses the claim. This external review process is often mandated by state or federal law and provides an impartial third-party evaluation of Cigna’s decision. For those facing a permanent coverage exclusion, practical alternatives can help manage the high cost of semaglutide. Patients can check for manufacturer savings cards or coupons, which can significantly reduce the out-of-pocket expense for those with commercial insurance, even if the claim is denied. Exploring self-pay options through discount pharmacies or patient assistance programs is also a necessary step when insurance coverage is unavailable.