Semaglutide, known by brand names such as Wegovy, has emerged as a significant medication for chronic weight management. As its use becomes more widespread, individuals often inquire about insurance coverage. This article explores Cigna’s policies and procedures regarding semaglutide for weight loss.
Cigna’s Approach to Semaglutide Coverage
Cigna’s stance on covering semaglutide for chronic weight management is not uniform across all its plans. Many Cigna plans may offer coverage for medications like Wegovy, but it is rarely automatic. Coverage typically requires prior authorization and a demonstration of medical necessity. Cigna’s policies are subject to change and vary significantly depending on the specific health plan.
Some Cigna insurance plans, particularly employer-sponsored ones, might exclude weight loss medications entirely. Where coverage is available, semaglutide is often categorized as a tier-4 (non-preferred) drug, which means it will require prior authorization. This indicates that while coverage is possible, it is contingent on meeting specific criteria and navigating the insurer’s approval processes.
Specific Requirements for Coverage
For Cigna to cover semaglutide for weight loss, specific medical criteria and preconditions must be met. Patients need to be at least 18 years old. A primary requirement involves a Body Mass Index (BMI) of 30 kg/m² or higher. Alternatively, coverage may be considered for individuals with a BMI of 27 kg/m² or higher who also have at least one weight-related comorbidity.
These comorbidities can include:
Hypertension
Type 2 diabetes
Dyslipidemia (high cholesterol)
Obstructive sleep apnea
Established cardiovascular disease
Knee osteoarthritis
Asthma
Chronic obstructive pulmonary disease (COPD)
Metabolic-dysfunction associated steatotic liver disease (MASLD/NAFLD)
Polycystic ovarian syndrome (PCOS)
Coronary artery disease (CAD)
Cigna also requires documentation of a prior attempt at weight management through lifestyle interventions, such as a structured diet and exercise program, for at least three months without successful reduction. The medication should not be used concurrently with other weight loss drugs.
Steps to Obtain Coverage
Obtaining Cigna coverage for semaglutide involves a structured process beginning with the patient’s healthcare provider. The first step requires a thorough consultation with a doctor to assess medical history and determine if semaglutide is an appropriate treatment. If the doctor deems it medically necessary and consistent with Cigna’s criteria, they will issue a prescription.
Following the prescription, the healthcare provider’s office is responsible for submitting a prior authorization request to Cigna. This request includes detailed documentation of the patient’s medical necessity, such as BMI, weight-related comorbidities, and records of previous weight management efforts. Cigna reviews this information to ensure the medication aligns with its coverage policies.
What to Do if Coverage is Denied
Despite meeting requirements, semaglutide coverage can sometimes be denied. If this occurs, understanding the reason for the denial is the immediate next step. Cigna’s denial letter typically provides specific details regarding the rationale, often referencing policy provisions. Patients should gather all relevant documentation, including the denial letter, complete medical records, and a copy of their insurance policy.
The next course of action is to initiate an internal appeal with Cigna. This involves submitting a written request to reevaluate the denied claim, providing a clear explanation of why the decision should be overturned and attaching all supporting documents. If the internal appeal is unsuccessful, policyholders may pursue an external review, where an independent third party assesses the claim.
Understanding Plan Variations
Cigna offers a diverse range of health plans, and semaglutide coverage can differ considerably among them. Coverage is highly dependent on the particular policy, whether it is an employer-sponsored benefit, an individual plan, or a Medicare Advantage plan. Specific exclusions for weight loss medications within a plan’s terms can also impact coverage.
The most accurate and current information regarding individual coverage will always be found in the specific Cigna plan documents or by contacting Cigna customer service directly. Reviewing the plan’s formulary, its list of covered drugs, can also provide clarity on whether semaglutide is included and under what conditions. This direct verification ensures patients have the precise details applicable to their unique insurance benefits.