Quick answer: Wegovy prior authorization is your insurer’s approval step before it pays. The typical criteria are a BMI of 30 or higher, or 27 or higher with a weight-related condition, at least 6 months in a lifestyle program, and, to renew, at least 5% weight loss after about 3 months on a stable dose.[1][2] Some plans require a BMI of 35, and some Medicaid programs require you to try older weight-loss drugs first.[2][4]

Prices and program terms checked October 2026. They change often; confirm with the manufacturer or your plan.

Wegovy contains semaglutide and is approved for weight management, heart risk reduction and MASH liver disease.[7] Each use can have its own prior authorization (PA) criteria. Before starting PA, make sure your plan covers weight-loss drugs at all; see does insurance cover Wegovy.

Typical criteria for weight management

The common thresholds track the trials that led to approval. STEP 1 enrolled adults with a BMI of 30 or more, or 27 or more with at least one weight-related condition, and without diabetes.[5]

CriterionAetna (standard)Aetna (BMI 35 version)FEP Blue
BMI, adults≥30, or ≥27 + condition[1]≥35[2]≥30, or ≥27 + heart disease or condition[3]
Lifestyle program6+ months before starting[1]6+ months before starting[2]Participation required[3]
Renewal≥5% weight loss or maintained[1]≥5% after 3+ months at maintenance dose[2]≥5% weight loss or maintained[3]
Teens 12 to 17—BMI ≥95th percentile[2]BMI ≥95th percentile[3]

Weight-related conditions usually include high blood pressure, type 2 diabetes, high cholesterol, sleep apnea and heart disease.[1][4] Plans also commonly require that you are not taking another GLP-1 at the same time.[3]

Step therapy

Some plans make you try cheaper drugs first. Michigan’s Medicaid criteria, as published by one plan, list Wegovy as non-preferred and require a trial of, or a medical reason against, all five types of older preferred weight-loss drugs, including phentermine and orlistat.[4]

Lifestyle programs

About a third of large employers that cover GLP-1s for weight loss require a dietitian visit, case management or a lifestyle program.[13] FEP Blue accepts a comprehensive weight management program, such as one offered through the plan.[3]

Criteria for heart risk and MASH

Heart risk reduction. Aetna requires established heart disease (prior heart attack, stroke, symptomatic peripheral artery disease or revascularization), a BMI of 27 or more, no type 2 diabetes and current standard heart treatment.[2]

MASH. Aetna requires stage F2 to F3 fibrosis confirmed by testing or biopsy, with a gastroenterologist or liver specialist involved.[2]

Why renewal hinges on 5%

Renewal rules check that the drug is working. In STEP 1, adults on semaglutide 2.4 mg lost an average 14.9% of body weight over 68 weeks, versus 2.4% on placebo.[5] In STEP 4, people who reached the 2.4 mg dose and then switched to placebo regained 6.9% of their weight, while those who continued lost a further 7.9%.[6] Plans use the 5% mark to separate people who respond from those who do not.

How to improve your approval odds

  1. Get a dated, measured BMI in your chart, not a self-reported weight. Plans often ask for the BMI at the start of therapy.[2]
  2. List every weight-related diagnosis you actually have, with dates: high blood pressure, high cholesterol, prediabetes, sleep apnea, heart disease.
  3. Document the lifestyle program. Keep notes, dates and the program name for at least 6 months of diet, activity and behavior work.[1]
  4. Record past medicines for weight loss and why they stopped, in case of step therapy.[4]
  5. Use the right form and policy. Ask the plan which policy number applies, because criteria differ between versions.[1][2]
  6. Track progress for renewal. Record weight at each visit so the 5% loss is easy to show.[2]

Who does what

Your prescriber’s office submits the PA request, usually through an electronic form or the plan’s portal. You can help by gathering records and calling the plan to confirm which form and policy apply. Pharmacies often flag a PA requirement when they try to fill the prescription, which is the most common way people discover they need one.

Switching drugs or plans

Approvals are tied to a specific drug and plan. When CVS Caremark moved its main commercial formularies from Zepbound to Wegovy on July 1, 2025, members with an active Zepbound approval did not need a new one to switch.[11] That kind of transfer is not automatic in every case. If you change plans, change drugs or move between the pill and the pen, ask whether a new request is needed.

How long PA takes

  • Commercial plans: the insurer generally must give its decision within 15 days for a prior authorization request, or 72 hours in urgent cases.[8]
  • Medicare drug plans: a decision within 72 hours of receiving the prescriber’s supporting statement, or 24 hours if expedited.[9]
  • Medicare GLP-1 Bridge: your prescriber submits PA to CMS. Once approved, it is valid through December 31, 2027, including refills and dose changes, unless you switch GLP-1s.[10]

If your PA is denied

  1. Read the denial. It should cite the criterion you missed.
  2. Fix and resubmit if the problem was missing records.
  3. File an internal appeal within 180 days. Decisions are generally due within 30 days for care not yet received, or 4 business days if urgent.[8]
  4. Request external review by an independent reviewer if the appeal fails.[8]
  5. Ask for a formulary exception if your plan prefers a different drug. CVS Caremark, for example, allowed case-by-case exceptions when the preferred drug did not work or caused intolerable side effects.[11]

A benefit exclusion is different. If your plan does not cover weight-loss drugs at all, there is usually no medical appeal. Blue Cross Blue Shield of Massachusetts, for example, says its 2026 obesity GLP-1 exclusion cannot be appealed.[12]