Wegovy prior authorization criteria: Blue Cross Blue Shield

Wegovy is a brand-name medication approved by the Food and Drug Administration (FDA) for weight loss in certain patients, including children 12 and older. It should be used together with a reduced-calorie diet and increased physical activity. 

Depending on your specific insurance plan, Blue Cross Blue Shield (BCBS) may cover Wegovy if patients meet specific criteria. Examples include a body mass index (BMI) at a certain level and weight-related medical conditions. Some plans may require prior authorization before they cover Wegovy, meaning they’ll request more information from the prescriber before agreeing to cover the medication. 

Read on to learn more about why Wegovy prior authorization may be required and the Blue Cross Blue Shield Wegovy prior authorization criteria. 

Blue Cross Blue Shield Wegovy coverage

BCBS is one of the largest healthcare insurance companies in the United States. It’s comprised of 34 independent, locally operated companies within the country. And as of December 2023, BCBS covers nearly 118 million people, which is about 1 in 3 Americans. 

Each BCBS insurance plan varies in what they cover, including medications. In some cases, insurance plans require prior authorization—also known as pre-authorization—before they approve medical services, procedures, or medicines. This ensures the treatment is medically necessary for you. Prescription weight-loss medications, such as Wegovy, often require prior authorization before they’re covered. So, there is a chance your BCBS plan will require prior authorization before it covers Wegovy. But even with prior authorization, your plan isn’t guaranteed to cover Wegovy. 

Wegovy prior authorization criteria

A prior authorization ensures a drug is being prescribed safely and is of medical necessity. In most cases, your healthcare provider will initiate the prior authorization for Wegovy and will work with your BCBS plan to complete the request. If the prior authorization is approved, the medication will be covered. However, it may only be covered for a certain length of time. After that period ends, your coverage may need reapproval, which in most cases will be handled by your pharmacy, insurance company, and healthcare professional. This time period varies depending on your plan, so it’s a good idea to check with your doctor, pharmacist, or BCBS insurance administrator about how long your Wegovy coverage will last.  

In order to meet the Wegovy preauthorization criteria, patients will have to meet the eligibility requirements the FDA approved it for:

• Adults with a BMI of 30 or higher
• Adults with a BMI of 27 or higher and at least one weight-related medical condition, such as high blood pressure, high cholesterol, or Type 2 diabetes
• Children 12 years and older with a BMI in the 95th percentile or higher

Blue Cross Blue Shield prior authorization form

The Blue Cross Blue Shield prior authorization form for Wegovy will vary by plan. Typically, the form may ask for your contact information, date of birth, prescriber’s information, the diagnosis for Wegovy (reason for taking it), and the dosage prescribed by your physician. The prior authorization form will also ask questions that help the plan determine if you meet its criteria for approval. 

Remember, your healthcare provider will complete the form and should be familiar with the process. Aside from the Wegovy BMI eligibility questions, here are some other questions that may be on the BCBS prior authorization form:

• Does the member have a history of pancreatitis?
• Will the member use Wegovy in combination with another glucagon-like peptide-1 receptor (GLP-1) agonist?
• Will the member participate in a weight loss regimen that includes a low-calorie diet, increased physical activity, and behavioral modifications while on Wegovy treatment?
• Has the member tried and failed a non-GLP-1 agonist weight-loss medication within six months
• For renewal requests: Has the member achieved weight loss of at least 5% of the baseline weight?

Wegovy prior authorization process

Once a healthcare provider prescribes Wegovy, the prescription will be sent to the patient’s preferred pharmacy. If their Blue Cross Blue Shield plan requires prior authorization, the pharmacy will notify the member’s healthcare provider. The healthcare provider will then complete the prior authorization request and submit it to the insurance company—a team of physicians, pharmacists, or other healthcare providers who will review the forms and documents and then decide whether to approve or deny the prior authorization. 

It can take up to 10 business days for BCBS to make a final decision. But, if approved, Wegovy will be covered according to the specifications of the plan, and the pharmacy will dispense the drug. If denied, BCBS will notify the prescribing healthcare provider. The patient can then choose to pay the full out-of-pocket cost or use an alternate medication prescribed by their healthcare provider. Alternatively, the healthcare provider can submit an appeal on their patient’s behalf, explaining why they need the medication covered by insurance. 

How much does Wegovy cost?

Without insurance or any discounts applied, Wegovy has a list price of $1,349.02 per package, which is equivalent to about $16,188 per year. If your Blue Cross Blue Shield plan covers Wegovy, the copay can vary depending on the plan. One person’s BCBS plan may be different from another’s. 

There may be other options to lower the cost of Wegovy, such as using a savings offer from the drug manufacturer or a prescription discount card. SingleCare offers a free Wegovy coupon that can help you save. To find the most accurate price, enter the correct dosage and quantity for your Wegovy prescription on the SingleCare coupon page. Then, choose the coupon for your preferred pharmacy. Save the coupon and show it to your pharmacy so they can apply the savings. 

How to check whether your BCBS plan covers Wegovy

The first step in determining if Wegovy is covered by your plan is to check your plan documents. These should provide information about coverage details and drug formularies, which are the prescription medications your plan covers. If this information isn’t in your plan documents, you may also check your plan’s website or call the toll-free phone number on the back of your insurance card.