How to get prior authorization for Wegovy: Criteria and steps  

Popular weight loss injection Wegovy (semaglutide) often requires prior authorization before insurance covers it. In this article, find out everything you need to know about how to get prior authorization for Wegovy. Topics include what it is and why you need it, real user experiences with prior authorization, and what to do if your request is denied.

Need weight loss medication, like Wegovy, and want insurance to cover it? Find a weight loss provider on Klarity who can help you navigate the prior authorization process to get your medication covered.

What is prior authorization and why do you need it for Wegovy (semaglutide)?

Prior authorization (PA) is a process insurance companies use to make sure that a prescribed treatment or medication is medically necessary. It involves your healthcare provider submitting paperwork that justifies your use of the treatment. Prior authorization also helps insurers manage costs as they can require you to try a lower-cost alternative before they’ll cover a more expensive option.

You only need to request prior authorization if you have a prescription for Wegovy, you’re insured, and your insurer requires it before covering the medication. To find out if you need prior authorization, call the customer service number on the back of your insurance card.  

How to get prior authorization for Wegovy

Getting prior authorization for Wegovy doesn’t have to be stressful. Follow these steps to get your medication approved by insurance.

Step 1: Have a healthcare provider evaluate your weight loss needs

To get prior authorization for Wegovy, you first need a prescription from a licensed healthcare professional. Providers who can prescribe Wegovy include physicians, physician assistants/associates (PAs), and nurse practitioners (NPs). Marketplace services, like Klarity, can connect you with an online weight loss specialist who will evaluate your goals and medication needs. 

Your provider can give you a prescription for Wegovy if it’s appropriate and safe for you. It’s U.S. Food and Drug Administration (FDA)-approved for weight loss in adults who are obese or overweight, as well as pediatric patients over 12 who qualify as obese. Wegovy also reduces the risk of a major cardiovascular event, such as heart attack, stroke, or death, in adults with obesity or overweight. You can get a prescription for Wegovy online, but an in-person evaluation or lab testing may be required.

Once you have a prescription, reach out to your insurance company to verify whether you need prior authorization for Wegovy.

Step 2: Submit a prior authorization request to your insurance company

If your insurance company requires prior authorization for Wegovy, have your healthcare provider submit the request. Getting approval requires sharing detailed information from your medical record, like your health history and medications you’ve already tried. Your provider’s office likely has a process in place for this. For a smoother process, share any information you receive from your insurer specific to your plan with your provider.

Step 3: Follow up with your insurance provider

Prior authorization approval can happen in minutes or take several days, and even weeks. It depends on whether your insurer’s process is automated or human review is required. You can check the status of your approval by calling your insurance company.

Step 4: If you’re approved, start on Wegovy

Once you receive approval, you can start taking your medication. Fill your prescription at your pharmacy of choice and take it as directed by your healthcare provider.

Real user experiences with Wegovy prior authorization

Real Wegovy users share personal experiences navigating the prior authorization process on websites like Reddit. Information shared in Wegovy reviews can be helpful when requesting prior authorization yourself. 

Some tips gleaned from the WegovyWeightLoss Reddit thread are:

• Necessary-Brief-2429 says, “My doctor put in a PA and I had an answer that same day. Some take a few business days to process, so if it was entered this past Thursday, I’d call [your insurance company] if you haven’t heard by Tuesday”.
• Rxsangria, who started Wegovy in 2023, says their insurance plan requires prior authorization when starting Wegovy and for each dose increase. According to their plan, prior authorization can be requested up to 30 days before their prescription should be filled. Because of this, their provider can request approval for no more than 2 doses of Wegovy at a time. 
• PriorAuth-APPROVED, who claims they’re a prior authorization specialist, says, “Usually insurance will require you to prove the medication is working for you by documenting how much weight you have lost, which should be 5% or more. Let your doctor know to report your baseline weight and current weight while on the medication [to prevent losing prior authorization approval with dose increases and insurer policy changes].”
• In response to a question about maintaining approval for Wegovy once body mass index (BMI) dips below 27 (the lowest BMI eligible for Wegovy), PriorAuth-APPROVED said, “Every insurance plan is different and has different criteria so it’s hard to say for you specifically. Some insurance plans will no longer cover the medication if your BMI is [less than] 27 with no comorbidities, some will deny the PA but an appeal will overturn the decision, and others will simply approve the PA if it’s submitted for continuation of therapy”.

Experiences shared by real Wegovy users don’t replace advice from your healthcare provider, insurance company, or pharmacist. The information submitted in your prior authorization request is specific to you. While advice from Wegovy reviews can help navigate this process, your healthcare provider is the best person to work with to get approval for Wegovy.

What to do if your prior authorization for Wegovy is denied

Of U.S. adults who take prescription medication and have health insurance, 19% face issues with prior authorization, including getting denied. If you’re denied prior authorization, don’t worry. There are things you can do to get the decision overturned.

Reasons prior authorization requests for Wegovy are denied

The most common reasons prior authorization is denied are:

Administrative or procedural errors

If there’s a problem with the paperwork submitted with your request, prior authorization approval may be denied. This could be clerical errors or missing information and test results. 

Doubts regarding medical necessity

Your insurance company may deny prior authorization if they have doubts about the medical necessity of Wegovy in your case. Some insurers deny coverage of prescription weight loss medications if you don’t have a concurrent medical issue, such as type 2 diabetes, or meet approved BMI criteria.

Cost management

Insurance companies do their best to conserve funds while helping as many people as possible get the treatment they need. Sometimes they’ll deny more expensive options in favor of lower-cost alternatives, especially if you haven’t tried and failed a low-cost medication before requesting approval for the pricier option.

Your plan doesn’t cover Wegovy

Prior authorization could be denied if your plan doesn’t cover Wegovy. In this case, ask for a list of covered alternatives and share it with your healthcare provider. They can help you determine if there’s one worth trying.

How to appeal prior authorization denials for Wegovy

To appeal a prior authorization denial for Wegovy, first reach out to your insurer and find out why you were denied. Administrative errors and doubts about medical necessity may be easily overturned by submitting additional information. If this isn’t the case, you or your healthcare provider can continue with the appeals process. 

Most states have 3 levels of appeals. First-level appeals involve a phone call to your insurance company asking for reconsideration. It may be best for your healthcare provider to do this as insurers are required to let your provider talk to the reviewer about the decision. Also, your provider may need to submit additional medical information as evidence that your approval was wrongly denied.

Second-level appeals involve review by a medical director at your insurance company. The goal is to prove your request should be accepted within your plan’s coverage guidelines. If the denial persists, the appeal goes to the final level — independent external review. A licensed healthcare professional and an independent reviewer at your insurance company evaluate your request then approve or deny based on medical necessity.

Talk to your healthcare provider if you have questions about navigating the appeals process. It may seem tricky, but together, you and your provider can make sure you get the treatment you need.

How to get Wegovy without insurance coverage

You can still get Wegovy for weight loss if your insurance company denies you coverage. A 1-month supply of Wegovy injection pens retails for around $1,430, according to drugs.com. While this is pricey, there are ways to save on Wegovy without insurance.

You may be eligible to get Wegovy for free, or at least less, with Novo Nordisk’s Wegovy Savings Card. The amount you save with the card depends on whether you have insurance coverage or pay cash for your prescriptions. Novo Nordisk also sponsors a Patient Assistance Program (PAP) which allows patients who qualify to get free medication from the manufacturer. Visit the NovoCare Patient Assistance Program website to find out if you qualify.

Wegovy coupons provide another way to save money on your prescription. Download or print coupons from prescription discount websites like GoodRx, Optum Perks, SingleCareRx, and drugs.com and present them to your pharmacy to access savings.

Key takeaway

Prior authorization (PA) is a process insurance companies use to make sure a prescribed medication is medically necessary. It’s often required for weight loss injections like Wegovy. Once you have a valid prescription from a licensed healthcare professional, have them submit a prior authorization request to your insurance company. Follow up with your insurer until you receive a decision. If you’re approved, you can start on Wegovy right away.

Reviews from real Wegovy users indicate that prior authorization isn’t always a straightforward process. Many receive denials or have to request approval with each Wegovy dose increase. Prior authorization can be denied for a number of reasons, including administrative errors, doubts about medical necessity, and cost management. 

If you’re denied prior authorization, you have the right to appeal. Typically, there are 3 levels of appeals — 2 internal and 1 external. It’s important to work with your healthcare provider and insurance company throughout this process and follow up regularly.

Without insurance coverage, Wegovy is expensive, retailing for $1,430 per month. If prior authorization is denied, you can save on your prescription using the Wegovy Savings Card or Novo Nordisk’s Patient Assistance Program if you’re eligible. You can always access savings with coupons from prescription discount sites regardless of insurance coverage and use them anywhere you find Wegovy in stock. 

Get a prescription for Wegovy from a provider on Klarity in as little as 24 hours

Ready to start your weight loss journey? With Klarity, you can have an appointment with an online weight loss specialist in as little as 24 hours. They can evaluate your need for weight loss medication, like Wegovy. Find a provider on Klarity to start your journey today.

Sources

Academy of Managed Care Pharmacy, Prior Authorization, Jul. 2019, https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/prior-authorization

Accreditation Council for Medical Affairs, What is Prior Authorization?, Amanda DeMarco, Dec. 2020, https://www.priorauthtraining.org/prior-authorization/

American Academy of Family Physicians, Precertification, Denials, and Appeals: Reducing the Hassles, Anthony N. Akosa, MD, MBA, Jun. 2006, https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html 

CoverMyMeds, 7 Common Prior Authorization Hurdles and How to Overcome Them, Miranda Delatore, MSN, RN, NEA-BC, Mar. 2022, https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-them

DailyMed, Label: Wegovy- semaglutide injection solution, https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b

Drugs.com, Wegovy Prices, Coupons, and Patient Assistance Programs, https://www.drugs.com/price-guide/wegovy

KFF, Consumer Problems with Prior Authorization: Evidence from KFF Survey, Karen Pollitz, et al., Sept. 2023, https://www.kff.org/affordable-care-act/issue-brief/consumer-problems-with-prior-authorization-evidence-from-kff-survey/

NovoCare, Patient Assistance Program, https://www.novocare.com/diabetes/help-with-costs/pap.html

Novo Nordisk, Wegovy, Coverage and savings, https://www.wegovy.com/coverage-and-savings/

Reddit.com, WegovyWeightLoss, https://www.reddit.com/r/WegovyWeightLoss/

The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health.

How we reviewed this article: This article goes through rigorous fact-checking by a team of medical reviewers. Reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the author.