Getting approved for Wegovy involves two separate hurdles: qualifying medically and getting your insurance to cover it. The medical criteria are straightforward, but the insurance process can take weeks and often requires documentation of previous weight loss attempts. Here’s what you need to know about both.
Who Qualifies for Wegovy
The FDA approved Wegovy for two groups of adults. The first is anyone with a BMI of 30 or higher, which meets the clinical definition of obesity. The second is anyone with a BMI between 27 and 29.9 who also has at least one weight-related health condition, such as high blood pressure, type 2 diabetes, high cholesterol, or obstructive sleep apnea.
Teens aged 12 and older can also qualify, but the threshold is different. Rather than a fixed BMI number, they need a BMI at or above the 95th percentile for their age and sex, which corresponds to obesity in pediatric growth charts.
Your doctor will calculate your BMI and review your medical history. There’s no single required blood test before starting, but if you have diabetes, your provider will want baseline blood sugar levels. They’ll also check your kidney function and monitor your heart rate during treatment.
Conditions That Disqualify You
A few medical situations make Wegovy off-limits entirely. You cannot take it if you or anyone in your family has ever had medullary thyroid carcinoma, a specific type of thyroid cancer. The same applies if you have a rare condition called Multiple Endocrine Neoplasia syndrome type 2, which causes tumors in your glands. A history of a serious allergic reaction to semaglutide (the active ingredient) also rules it out, as does active diabetic ketoacidosis.
Beyond these hard stops, your doctor will weigh other factors carefully. A history of pancreatitis, gallbladder disease, or severe kidney problems doesn’t automatically disqualify you, but it may influence whether your provider considers the medication appropriate.
The Insurance Prior Authorization Process
Even if you meet every medical criterion, most insurance plans won’t simply fill a Wegovy prescription at the pharmacy counter. They require something called a prior authorization, which is essentially your doctor making a formal case to the insurer that the medication is necessary for you. This is where many people hit delays.
Your provider will typically need to submit your most recent BMI, a list of your weight-related health conditions with diagnostic codes, a treatment plan that includes lifestyle changes like diet and exercise, and documentation of previous weight loss therapies you’ve tried. The more thorough this paperwork is, the better your chances of a quick approval.
Step Therapy: Trying Other Treatments First
Some insurance plans require “step therapy” before they’ll approve Wegovy. This means you need documented evidence that you tried and didn’t get adequate results from at least one lower-cost weight loss medication first. The most commonly required alternatives are naltrexone/bupropion (a combination pill) and phentermine/topiramate.
A study of U.S. commercial health plans found that some insurers specifically mandate trying one of these medications before authorizing semaglutide coverage. If your plan has this requirement, your doctor will need to prescribe the alternative first and document that it was either ineffective or caused side effects you couldn’t tolerate. This process alone can add months to your timeline, so it’s worth asking your insurer upfront whether step therapy applies to your plan.
Not all plans require this. Some accept a documented history of supervised diet and exercise programs that didn’t produce lasting results. Others have no step therapy requirement at all. Your insurance company’s pharmacy benefits line can tell you exactly what your plan demands.
What to Do if You’re Denied
An initial denial isn’t the end of the road. Most insurers have a formal appeals process, and many denials get overturned on appeal when additional documentation is provided. Common reasons for denial include incomplete paperwork, a BMI that was recorded incorrectly, or missing documentation of previous weight loss efforts.
If your doctor’s office has experience with Wegovy prior authorizations, they’ll often handle the appeal for you. Ask them specifically whether they have a staff member who manages insurance appeals, as larger practices frequently do. A peer-to-peer review, where your doctor speaks directly with the insurance company’s medical reviewer, can also be effective at resolving denials.
Paying Without Full Insurance Coverage
Wegovy’s list price is high enough that most people can’t pay out of pocket long-term. The manufacturer, Novo Nordisk, offers a savings program that can bring your cost down to as little as $25 per month for a 28-day supply of the weekly injections. This program is available to people with or without insurance, and you can find the savings card on the manufacturer’s website.
If you have commercial insurance that covers Wegovy but leaves you with a high copay, the same savings card functions as a copay card to reduce your out-of-pocket cost. However, these programs typically don’t apply to government insurance like Medicare or Medicaid. If you’re on one of those plans, you’ll need to check your specific formulary for coverage details.
Keeping Your Prescription Active
Getting the initial approval is only the first step. Most insurance plans require re-authorization after a set period, often 6 or 12 months. At that point, your insurer will want to see that the medication is working. While the specific weight loss percentage required varies by plan, your doctor will need to document your progress, including how much weight you’ve lost and whether your weight-related health conditions have improved.
This means keeping your follow-up appointments matters for more than just your health. Every visit where your provider records your weight, blood pressure, and other metrics creates the paper trail your insurer will ask for at re-authorization time. Missing appointments can leave gaps in documentation that make re-approval harder.
Supply Is No Longer a Major Barrier
Throughout 2023 and 2024, widespread shortages of semaglutide injection products made it difficult for even approved patients to fill their prescriptions. As of February 2025, the FDA determined the national shortage is resolved, with the manufacturer’s production capacity meeting projected demand. You may still encounter occasional localized delays as products move through distributors to individual pharmacies, but the months-long waits that characterized the shortage period are largely over.
If your pharmacy can’t fill your prescription immediately, ask them to check availability at nearby locations or through their mail-order pharmacy option. Specialty pharmacies that focus on injectable medications often have more reliable stock than retail chains.