Wegovy (semaglutide) is an FDA-approved medication for chronic weight management and reducing the risk of cardiovascular events in adults with heart disease who are either obese or overweight. Given its potential benefits, understanding insurance coverage for Wegovy is crucial for those considering it as part of their weight loss journey. This article provides a comprehensive guide to navigating Wegovy insurance coverage requirements.
Initial Steps: Checking Coverage and Costs
The first step in determining Wegovy coverage is to check your individual insurance plan details. Wegovy® insurance coverage depends on your insurance company, as well as the medication coverage provided in your individual plan. Major health insurance plans tend to offer several different types of plans, whether employer-sponsored or individually obtained. Coverage can vary greatly between plans, even if they’re offered by the same insurance company, so it is important to verify coverage for Wegovy. Each individual will have a list of medications that are covered (the prescription “formulary”) along with whether or not there are specific eligibility requirements for each medication. You can usually find the phone number on the back of your insurance card.
- Online Resources: Novo Nordisk, the maker of Wegovy®, offers an online platform where you can check your insurance coverage and access potential savings offers. On the platform, you’ll be asked some questions. To get started, you'll select if you're a patient or caregiver, and then move on to insurance details. After that, you’ll enter some key pieces of information including your name, date of birth, gender, and zip code. Once you've filled those out, go ahead and review them. If everything looks good, read the content and check the consent box at the bottom. Then, click the button underneath to continue. Here, you'll enter your health care professional's first and last name, city and state. Your health care professional is your prescribing physician, nurse practitioner or physician assistant.
- Direct Contact: Call your insurance company directly to inquire about Wegovy coverage. When calling, it's helpful to ask specific questions such as:
- Is Wegovy covered under my plan?
- What is my cost (or copay) for Wegovy?
- Do I need prior authorization?
- Are there specific eligibility requirements?
- Do I have any out-of-pocket costs before medicines are covered?
- Which other weight loss maintenance products are covered, if any?
- Check the Formulary: Your coverage will vary based on the plans offered by your employer and the plan that you choose when electing your annual benefits. Each individual will have a list of medications that are covered (the prescription “formulary”) along with whether or not there are specific eligibility requirements for each medication.
- Novo Nordisk: You can also call Novo Nordisk or check your coverage immediately online, with a form you fill out.
Understanding Prior Authorization
Based on the answers you submitted, you’ll find out if your insurance covers Wegovy®. If your insurance doesn't provide coverage, or is unable to provide immediate coverage details, we can share options that may help. If your result is not covered, you may submit an appeal or request for coverage with the help of your health care professional.
Many insurance plans require prior authorization for Wegovy. If you see this, don’t worry. It means that your health insurance company might need to approve your prescription. Your health care professional will fill out a prior authorization form and submit it to the insurance company. The insurer will look at the prior authorization to determine whether they will cover the medicine under your insurance plan. It will communicate its decision and rationale to you and/or your health care professional. This process involves your healthcare provider contacting your insurance company to request approval for the medication.
- Criteria: Insurers may require that you meet the prescribing criteria set by the drug manufacturer. If you don’t meet this criteria, your insurance plan may not cover Wegovy. To determine if you meet the criteria for Wegovy, several factors are considered:
- Body Mass Index (BMI): If your BMI is >30, or >27 and you have a weight-related medical condition such as high blood pressure or high cholesterol, you may be eligible.
- Previous attempts to lose weight: If you have attempted to lose weight through lifestyle changes such as a low calorie diet and exercise for at least 3 months and have been unable to lose or maintain weight loss, you may qualify.
- Other aspects including your medical history, current medications, and insurance coverage need to be considered.
- Denial: If you are turned down, ask why. It could be because you didn’t meet the criteria, but it could also be because your employer has opted out of weight loss benefits.
Factors Influencing Coverage Decisions
Several factors influence whether an insurance company will cover Wegovy:
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- Plan Type: Coverage can vary greatly between plans, even if they’re offered by the same insurance company. Benefits offered by employer plans also vary, and coverage is often based on what employers are willing to cover.
- Medical Necessity: Insurance companies often require documentation of medical necessity. The best way to get Wegovy covered by insurance is to work with an experienced medical provider, like those at Form Health, to determine if this medication is appropriate for you as part of an overall weight loss treatment plan. Once prescribed, Form can submit necessary paperwork, such as a prior authorization, to your insurance company to request coverage.
- Formulary: Wegovy® insurance coverage depends on your insurance company, as well as the medication coverage provided in your individual plan. Each individual will have a list of medications that are covered (the prescription “formulary”) along with whether or not there are specific eligibility requirements for each medication.
Insurance Company Policies
Several insurance companies, including Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare, typically cover Wegovy in some form or another. However, coverage varies by plan.
Government and Federal Programs
- Medicare: In general, Medicare does not cover medications indicated to treat overweight and obesity, although certain Medigap and Medicare Advantage plans for retirees will cover Wegovy. Medicare prescription plans do not cover Wegovy for weight loss, but some plans may cover it for heart-related use. Because Wegovy has an FDA approval for cardiovascular risk reduction, many Medicare prescription plans that may not have covered Wegovy for weight loss may now cover it for this use.
- Medicaid: For Medicaid, it is best to contact your insurance provider directly as coverage varies by state, but it is important to note that Form Health is unable to accept Medicaid insurance for program costs at this time. Every state decides what prescription medications to cover through Medicaid, so coverage for Wegovy depends on the reason for use and the state you live in. The expansion of Medicare coverage for weight-loss medications would increase their availability for many older adults who cannot afford them and have a “multiplier effect” because private insurers often follow Medicare’s lead.
- Veterans Administration (VA): The Veterans Administration (VA) covers obesity management for eligible veterans, but whether it will cover the cost of Wegovy varies. Wegovy is not on the VA national formulary and requires a non-formulary drug request and prior approval.
Cost-Saving Measures
The typical cash price of a 28-day supply (one month) of Wegovy is $1,8479, but that cost varies by pharmacy. Although it’s expensive, there are ways to save on Wegovy.
- Savings Card: If you have commercial insurance, and your doctor prescribes this medicine, it may be more affordable to gain access with a Wegovy Savings Copay Card supplied from Novo Nordisk, the manufacturer. The Wegovy® savings card can help lower those costs. If you have a yearly insurance deductible, you may need to meet your deductible before your insurance would pay for any part of your medicine.
- Patient Financial Assistance Program: If you do not have insurance, contact Novo Nordisk, the manufacturer, 1-888-809-3942 (Monday-Friday, 8:00 am-8:00 pm ET) to determine if you qualify for a Wegovy Savings Copay Card or patient financial assistance program. Government insured patients cannot use any copay cards offered by the manufacturer.
- NovoCare Pharmacy: In addition, for cash-paying customers without insurance, you may be able to access all strengths of Wegovy through the NovoCare Pharmacy. NovoCare Pharmacy provides direct-to-patient, convenient home shipments of Wegovy single-dose pens at a reduced cost of $499 per month. You may be able to access all strengths of Wegovy through the NovoCare Pharmacy. NovoCare Pharmacy provides direct-to-patient, convenient home shipments of Wegovy single-dose pens at a reduced cost of $499 per month.
- Pharmacies: Different pharmacies offer different prices for the same medication.
Important Considerations
- Weight Loss Expectations: Weight loss may begin within the first 4 weeks of treatment with Wegovy, but the full effects of Wegovy may not be seen for several months or longer.
- Multidisciplinary Approach: Although weight loss medication can help, it’s not a quick fix for obesity. “When we speak about obesity, we’re looking at a multi-disciplinary approach that includes behavioral interventions, lifestyle modifications, and pharmacology, “ says Raj Dasgupta, MD, a board-certified physician and associate professor of clinical medicine at the University of Southern California in Los Angeles.
- Side Effects:
- Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Wegovy® and medicines that work like Wegovy® caused thyroid tumors, including thyroid cancer.
- are pregnant or plan to become pregnant. Wegovy® may harm your unborn baby.
- are breastfeeding or plan to breastfeed.
- Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Wegovy® may affect the way some medicines work and some medicines may affect the way Wegovy® works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin.
- inflammation of your pancreas (pancreatitis). Stop using Wegovy® and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without nausea or vomiting.
- gallbladder problems. Wegovy® may cause gallbladder problems, including gallstones. Some gallstones may need surgery.
- increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas. This can be a serious side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Wegovy®.
- dehydration leading to kidney problems. Diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems. It is important for you to drink fluids to help reduce your chance of dehydration.
- severe stomach problems. Stomach problems, sometimes severe, have been reported in people who use Wegovy®.
- increased heart rate. Wegovy® can increase your heart rate while you are at rest.
- depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings.
- food or liquid getting into the lungs during surgery or other procedures that use anesthesia or deep sleepiness (deep sedation). Wegovy® may increase the chance of food getting into your lungs during surgery or other procedures.
- No Generic Version: Wegovy is only available as a brand name drug and a generic version is not yet available. There is no generic version of Wegovy available at this time, as Wegovy is a relatively new medication with patent protection. You may have heard of compounded semaglutide, which some believe to be the equivalent of a generic but it is actually different from the medication approved by the FDA.
Legislative Efforts
In July 2023, a bipartisan group in Congress reintroduced the Treat and Reduce Obesity Act (TROA), which would work to prevent diseases associated with obesity, including heart disease, stroke, Type 2 diabetes, and certain cancers that are leading causes of preventable death.
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