Wegovy Prior Authorization: Criteria, Approval Checklist, and What to Do If Denied

By Editorial TeamUpdated September 29, 2026

Editorial content. This article reports public information and is not medical advice. Disclaimer.

TL;DR

Wegovy PA checks that your prescription matches an FDA-labeled use and your plan's rules. There are three routes: weight management, cardiovascular risk reduction, and MASH liver disease.
Weight route: plans typically require BMI 30 or higher, or 27 or higher with a weight-related condition, plus use alongside diet and activity changes. Some add a documented weight-management program.
Heart route: adults with a prior heart attack, stroke, or symptomatic peripheral artery disease and a BMI of 27 or higher. Because it is not a weight-loss use, Medicare Part D plans may cover it, and some commercial plans cover it even when weight loss is excluded.
Timelines: Medicare Part D must decide within 72 hours (24 hours if expedited). Employer plans under federal ERISA rules generally have up to 15 days for a required pre-approval.
Renewal on the weight route usually requires documented weight loss of at least 5% from baseline. If you are denied, the reason code tells you whether to fix paperwork, switch indication, or appeal.

An abstract checklist of teal filled boxes with one orange outlined box, next to a medication pen outline. — Most Wegovy approvals come down to a complete checklist of documentation.

Your pharmacy says Wegovy "needs a prior authorization," or your plan has already said no. Either way, you are dealing with the same thing: before your insurer will pay, it wants proof that your prescription matches one of Wegovy's FDA-labeled uses and meets the plan's own rules.

This page explains what those rules usually are, how the heart and liver indications changed who can get coverage, how long decisions take, what renewal requires, and where to go next if you are denied. It covers Wegovy (semaglutide) injection 2.4 mg, with notes on the tablet and the higher-dose Wegovy HD where plan rules differ. Your own plan's criteria document always takes priority over any general guide, including this one.

What prior authorization for Wegovy actually checks

A prior authorization (PA) is a request your prescriber sends to your insurer or pharmacy benefit manager (PBM) before the plan will cover a drug. For Wegovy, the reviewer checks three things:

Is Wegovy covered at all on your plan? Many employer plans exclude drugs used for weight loss. If that exclusion applies, no amount of paperwork will get a weight-loss request approved, but a request under a different indication might still be possible (see below).
Which FDA-labeled use is being requested, and does the documentation support it? This is where most of the criteria live.
Does the request meet the plan's extra rules? Examples include age limits, a required weight-management program, step therapy, quantity limits, and who is allowed to prescribe.

Novo Nordisk's guidance for prescribers suggests the same order: check benefits and formulary status first, then submit a PA if the drug is covered, or a formulary exception if it is not on the formulary.

Wegovy's FDA-labeled uses (and why they matter for coverage)

Insurers build their PA criteria around the FDA label. As of the June 2026 prescribing information, Wegovy injection is indicated, together with a reduced-calorie diet and increased physical activity:

To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal heart attack, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. The FDA approved this use on March 8, 2024, based on the SELECT trial.
To reduce excess body weight and maintain weight reduction long term in adults and children aged 12 and older with obesity, and in adults with overweight plus at least one weight-related condition.
To treat noncirrhotic MASH (metabolic dysfunction-associated steatohepatitis, formerly NASH) with moderate to advanced liver fibrosis (stages F2 to F3) in adults. The FDA approved this use on August 15, 2025, under accelerated approval, which means continued approval may depend on a confirmatory trial.

Wegovy tablets carry the cardiovascular and adult weight-management indications, but not MASH or the pediatric use.

The label itself describes "obesity" and "overweight" rather than listing BMI cut-offs in the indication. The weight-management trials it summarizes enrolled people with a BMI of 30 or higher (obesity), or 27 to 29.9 plus at least one weight-related condition such as treated or untreated high cholesterol or hypertension (overweight). The cardiovascular trial enrolled adults aged 45 and older with a BMI of 27 or higher and a prior heart attack, prior stroke, or peripheral arterial disease; people with diabetes were excluded. Plans generally borrow these numbers.

Typical PA criteria by indication

Plans differ, so the examples below come from two current, published PBM and insurer policies: CVS Caremark's Wegovy criteria (policy 4774-C) and UnitedHealthcare's commercial weight-loss program (effective September 1, 2026). Treat them as examples of what reviewers look for, not as your plan's rules.

Weight management

Age: CVS Caremark's adult criteria require age 18 or older; there is a separate pediatric pathway for ages 12 to 17.
BMI: a baseline BMI of 30 or higher, or 27 or higher with at least one weight-related condition (examples given include hypertension, type 2 diabetes, dyslipidemia, and, in UnitedHealthcare's policy, sleep apnea). Both policies ask for documentation.
Lifestyle: use together with a reduced-calorie diet and increased physical activity.
Program participation: this varies a lot. CVS Caremark requires participation in a comprehensive weight-management program with continuing follow-up for at least 6 months before drug therapy. UnitedHealthcare's policy asks that the drug be used as an adjunct to lifestyle modification, such as dietary restriction, exercise, behavioral support, or a community-based program.
Switching from another weight-loss drug: CVS Caremark tells reviewers to use your BMI at the start of any weight-loss drug therapy. If you already lost weight on another medication, your earlier BMI is the one that counts.

Some plans also require step therapy, meaning you must try one or more lower-cost drugs first. That is covered in detail in our step therapy guide.

Cardiovascular risk reduction

Established cardiovascular disease, documented: a prior heart attack, a prior ischemic or hemorrhagic stroke, or symptomatic peripheral arterial disease. Both policies define symptomatic PAD as claudication with an ankle-brachial index below 0.85 at rest, a peripheral revascularization procedure, or amputation due to atherosclerotic disease. CVS Caremark also accepts prior coronary revascularization (bypass surgery, PCI, or angioplasty).
BMI of 27 or higher.
No type 2 diabetes. Both policies exclude diabetes on this route. CVS Caremark notes that Ozempic is indicated for cardiovascular risk reduction in adults with type 2 diabetes and established cardiovascular disease. UnitedHealthcare also excludes an HbA1c above 6.5% and NYHA class IV heart failure.
Standard heart treatment already in place: both policies want evidence that you are on guideline-directed therapy, such as a cholesterol-lowering drug and an antiplatelet, or a documented reason why you are not.
Age: UnitedHealthcare's cardiovascular policy requires age 45 or older, which matches the SELECT trial's enrollment.

MASH (noncirrhotic, F2 to F3 fibrosis)

Documented fibrosis stage F2 or F3 by a non-invasive test (for example, elastography such as FibroScan, or MR elastography) or a liver biopsy. UnitedHealthcare accepts a biopsy only if it was done within the past 12 months.
Specialist involvement: both policies require a prescription by, or in consultation with, a gastroenterologist or hepatologist.
Injection only: the tablet and Wegovy HD are not approved for MASH, and CVS Caremark's MASH criteria exclude both.
UnitedHealthcare also asks the prescriber to confirm that Wegovy will not be started at the same time as Rezdiffra (resmetirom) for the same condition.

For background on the heart and liver evidence, see GLP-1s and heart health and GLP-1s and liver health.

How the heart and liver indications changed coverage

Before March 2024, Wegovy's only labeled use was weight management. That meant a plan with a weight-loss drug exclusion had no route to cover it, and Medicare Part D could not cover it at all, because federal law bars Part D from covering drugs used for weight loss.

The cardiovascular indication changed that. Because reducing heart attack and stroke risk is not a weight-loss use, the exclusion does not apply to it.

Medicare Part D. In March 2024, CMS told Part D plans they could add Wegovy to their formularies for its cardiovascular use. KFF estimated that about 3.6 million Medicare beneficiaries had established cardiovascular disease and obesity or overweight in 2020, and so could be eligible. Two caveats: Part D plans are not required to cover Wegovy, and plans that do can apply prior authorization and step therapy. CMS's current guidance also lists MASH as a use eligible for Part D coverage.

The Medicare GLP-1 Bridge. From July 1, 2026, to December 31, 2027, CMS is running a separate program that gives eligible Part D enrollees Wegovy (injection and tablets), Zepbound KwikPen, or Foundayo for weight reduction at a $50 monthly copay. It has its own PA criteria (a BMI of 35 or higher, or lower BMI thresholds combined with specific conditions). CMS says a prescription written to reduce the risk of major adverse cardiovascular events should go to your Part D plan instead, and so should prescriptions for MASH. The Bridge has no appeals process; a prescriber can only resubmit with corrected or additional information. The full criteria and costs are on our Medicare GLP-1 coverage page.

Commercial plans that exclude weight loss. Some insurers now run a separate PA for the non-weight-loss uses. UnitedHealthcare's non-formulary Wegovy policy, for example, states that weight-loss drugs are typically a benefit exclusion but allows coverage of Wegovy for cardiovascular risk reduction and for MASH.

What this means for you: if your plan excludes weight-loss drugs but you have established heart disease or diagnosed MASH with F2 to F3 fibrosis, ask your prescriber whether a request under that indication is appropriate. The request has to reflect the real clinical reason for prescribing, and reviewers check the chart.

Your Wegovy PA approval checklist

Bring this list to your prescriber, or check it against what their office plans to submit. Most first-round denials trace back to one missing item.

For every request

Your plan's Wegovy criteria document (ask member services or check your PBM's website)
The correct indication named on the request: weight management, cardiovascular risk reduction, or MASH
A diagnosis code that matches that indication
Current height, weight, and BMI, with the date measured. If you switched from another weight-loss drug, include your baseline BMI from before any drug therapy.
A chart note showing Wegovy will be used with a reduced-calorie diet and increased physical activity
The exact product and dose (injection, tablet, or Wegovy HD), because some criteria exclude certain forms

Weight management, add:

Documented weight-related conditions if your BMI is 27 to 29.9
Records of any weight-management program, with dates, if your plan requires one
Step-therapy history (drug, dose, dates, weights, and why you stopped), if your plan requires it

Cardiovascular risk reduction, add:

Records showing the qualifying event or diagnosis: heart attack, stroke, symptomatic PAD, or (for some plans) coronary revascularization
Your current heart medications, or the documented reason you are not on them
Recent HbA1c if your plan screens out diabetes

MASH, add:

Fibrosis staging results (elastography, MR elastography, or biopsy) and the date
The gastroenterologist or hepatologist involved in your care

Novo Nordisk's prescriber guidance also flags the basics that get missed: patient and insurance ID numbers, prescriber NPI, and a treatment plan.

How long Wegovy prior authorization takes

Federal rules set the outer limits:

Plan type	Standard decision	Urgent or expedited
Medicare Part D plan	Within 72 hours of the request (or of the prescriber's supporting statement, for exceptions)	Within 24 hours
Medicare GLP-1 Bridge	Decisions sent to the prescriber within 72 hours	Not applicable
Employer plan under ERISA, where the plan requires pre-approval	Within 15 days (one 15-day extension allowed)	Within 72 hours

If a Part D plan misses its deadline, the missed deadline counts as a denial, and the plan must forward your case to an independent reviewer within 24 hours. For fully insured and marketplace plans, state law may set its own timelines.

In practice, most lost days come before submission, while records are gathered, or after it, when the plan asks for more information. That is why the checklist matters more than any deadline.

Approval length and reauthorization

A PA approval does not last forever. Examples from the two policies:

CVS Caremark (injection, adults, weight route): 8 months at first, then 12 months at each renewal. Cardiovascular and MASH approvals last 12 months. The tablet's first weight-route approval lasts 6 months.
UnitedHealthcare (weight-loss program): 5 months for Wegovy at first, then 12 months at each renewal. Its separate cardiovascular and MASH policy approves for 12 months.

What renewal usually requires:

Weight route: documented loss of at least 5% of baseline body weight, or maintenance of that initial 5% loss, plus continued lifestyle changes. CVS Caremark also asks for at least 3 months at a stable maintenance dose. The label allows a maintenance dose of 1.7 mg or 2.4 mg, and escalation to 7.2 mg (Wegovy HD) for some adults. See Wegovy dose escalation for how titration works.
Cardiovascular route: CVS Caremark and UnitedHealthcare do not set a weight-loss target for renewal. They check continued use with diet and activity, ongoing documentation of the cardiovascular disease (CVS Caremark), or the absence of diabetes and class IV heart failure (UnitedHealthcare).
MASH route: documentation of a positive clinical response, such as stable or improved fibrosis or better liver tests, and no progression to cirrhosis.

Note your renewal date; if the approval lapses, your next fill may be rejected until a new one goes through.

Common reasons Wegovy PAs are denied

Novo Nordisk lists the most common denial reasons its prescriber support team sees:

The patient does not meet the clinical criteria. Examples: a BMI of 27 to 29.9 with no weight-related condition documented, a missing required program, or no documented cardiovascular event on the heart route.
Wegovy is not covered, is non-formulary, or weight loss is a benefit exclusion. This is a plan-design issue, not a paperwork issue. It may call for a formulary exception or a different indication, if one genuinely applies.
The patient did not try and fail a formulary alternative. This is step therapy; see our step therapy guide.
An invalid diagnosis code was submitted. For example, the code does not match the indication requested.
Information was missing or not received in time. Chart notes, BMI dates, or fibrosis results did not reach the plan.

The policies above suggest two more: a cardiovascular request for someone with type 2 diabetes, and a request for a form the criteria exclude, such as Wegovy HD on CVS Caremark's heart or MASH routes.

What to do if your Wegovy PA is denied

Read the denial letter. Find the exact reason, the criteria it cites, and your appeal deadline.
Match the reason to the fix. Missing information usually means your prescriber can resubmit or add records. A plan exclusion means checking whether another indication genuinely applies to you, or asking about a formulary exception. A clinical-criteria denial usually means a formal appeal.
Ask about a peer-to-peer review. Novo Nordisk's prescriber guidance says a peer-to-peer discussion with the plan's medical director, or a further level of appeal, may help after a denial.
File the appeal with a letter of medical necessity. Our step-by-step appeal guide walks through internal appeals, peer-to-peer review, external review, and state complaints, with letter templates.

If your plan simply does not cover Wegovy, our GLP-1 insurance coverage guide explains how coverage differs across commercial, Medicare, and Medicaid plans. Insurance-first telehealth services that handle PA paperwork are compared in best insurance-friendly GLP-1 telehealth.

Paying cash while you wait

A PA or appeal can take weeks. If you and your prescriber decide to start or continue treatment in the meantime, Novo Nordisk's self-pay pharmacy, NovoCare, sells Wegovy directly with a valid prescription. As of September 2026, its prices are $349 a month for injection doses from 0.25 mg to 2.4 mg and $399 a month for Wegovy HD 7.2 mg. New patients get an introductory $199 a month on the 0.25 mg and 0.5 mg doses for the first two fills, through December 31, 2026. The tablets range from $149 to $299 a month depending on dose. These are self-pay prices; Novo's commercial savings offer is separate, and government beneficiaries are excluded from it.

For how to enroll, see our NovoCare Wegovy enrollment walkthrough. For every cash-pay route compared, see Wegovy without insurance.

This page explains how insurance approval generally works. It is not medical advice. Whether Wegovy is right for you, and under which indication, is a decision for you and your prescriber.

Related coverage guides

Frequently asked questions

What are the prior authorization criteria for Wegovy?

It depends on which FDA-labeled use your prescriber submits under. For weight management, plans typically require an adult BMI of 30 or higher, or 27 or higher with at least one weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia, with the drug used alongside a reduced-calorie diet and more physical activity. Some plans add a documented weight-management program; CVS Caremark's current criteria ask for at least 6 months. For cardiovascular risk reduction, plans typically require a documented prior heart attack, stroke, or symptomatic peripheral artery disease and a BMI of 27 or higher. For MASH, they require documented F2 to F3 liver fibrosis. Your plan's own criteria document is the final word.

How long does Wegovy prior authorization take?

Federal rules set outer limits. Medicare Part D plans must decide a standard request within 72 hours and an expedited one within 24 hours. Employer plans covered by ERISA must generally decide a required pre-approval within 15 days (72 hours if urgent), with one possible 15-day extension. In practice, most delay comes from missing documents: the clock usually cannot help you if the plan is waiting on chart notes from your prescriber.

Is there a standard Wegovy prior authorization form?

No single form works for every plan. Each insurer or pharmacy benefit manager uses its own PA form and criteria, and your prescriber's office usually submits it. Novo Nordisk's guidance for prescribers says the request should include patient and insurance details, BMI, comorbidities, previous therapies, prescriber information, and the treatment plan. Ask your plan, or check its website, for the Wegovy criteria document so you know exactly what it checks.

Does Medicare cover Wegovy with prior authorization?

Medicare Part D still cannot cover drugs used for weight loss alone, but Wegovy has FDA-labeled uses that are not weight loss. After the cardiovascular approval in March 2024, CMS told Part D plans they could add Wegovy for that use. Plans are not required to cover it and may use prior authorization. CMS also lists MASH as a Part D-eligible use. Separately, the Medicare GLP-1 Bridge covers Wegovy for weight reduction at a $50 copay from July 1, 2026, to December 31, 2027, for people who meet its own BMI criteria, with its own prior authorization.

What does Wegovy reauthorization require?

On the weight-management route, plans commonly require documented weight loss of at least 5% of baseline body weight, or maintenance of that loss, plus continued lifestyle changes. CVS Caremark's criteria also ask for at least 3 months at a stable maintenance dose. On the cardiovascular route, renewal criteria generally focus on continued use with diet and activity rather than a weight-loss target, though details vary by plan.

My plan excludes weight-loss drugs. Can I still get Wegovy covered?

Possibly, if you qualify for a non-weight-loss indication. For example, UnitedHealthcare runs a separate policy that allows coverage of Wegovy for cardiovascular risk reduction and MASH on plans where weight-loss drugs are a benefit exclusion. If you have established cardiovascular disease or diagnosed MASH with F2 to F3 fibrosis, ask your prescriber whether a request under that indication is clinically appropriate for you.

What should I do if my Wegovy prior authorization is denied?

Read the denial letter for the specific reason and the deadline. A denial for missing information can often be fixed by resubmitting with the right documents. A denial because weight loss is excluded may point to a different indication, if one applies to you. A denial on clinical criteria usually means a formal appeal with a letter of medical necessity. Our step-by-step appeal guide covers internal appeals, peer-to-peer review, and external review.