Wegovy (semaglutide 2.4 mg) and Ozempic (semaglutide 1 mg, approved for type 2 diabetes) are among the most prescribed medications in the United States. They're also among the most expensive. Wegovy lists at approximately $1,349/month without insurance. Whether your plan covers it depends on a maze of formulary decisions, prior authorization criteria, and federal law — and the answer changes year to year.
The Federal Exclusion and Its Exceptions
Medicare Part D was historically prohibited from covering weight loss medications under the Social Security Act (§1862(a)(1)(D)). This exclusion is why most commercial plans historically followed suit — they were designed around Medicare standards or chose to exclude obesity medications to control costs.
That is changing. The Treat and Reduce Obesity Act (TROA), if enacted, would end the Medicare exclusion. Several bills in 2025–2026 have addressed this. As of mid-2026, the political situation remains unresolved — check CMS.gov for the current status. If Medicare coverage expands, commercial plan adoption typically follows within 2–3 benefit cycles.
Commercial Insurance Coverage in 2026
The answer depends entirely on your specific plan:
- Large employer plans (ERISA): Roughly 40–50% of large self-insured employers now cover GLP-1 medications for obesity, up from 25% in 2023. Many require documented BMI ≥30 (or ≥27 with a weight-related comorbidity), failure of supervised diet program, and PA documentation.
- ACA marketplace plans: Coverage is inconsistent. Some silver/gold plans include GLP-1s on formulary with step therapy (metformin, bupropion/naltrexone first). Many exclude obesity medications entirely.
- Medicaid: Coverage varies dramatically by state and changes often. Check your state Medicaid plan's current criteria directly.
- Small group plans: Most commonly exclude GLP-1 obesity medications due to cost.
Prior Authorization: What to Expect
Even plans that cover Wegovy typically require prior authorization. Standard PA requirements include:
- Documented BMI ≥30 kg/m² (or ≥27 with documented comorbidity: hypertension, type 2 diabetes, dyslipidemia, OSA, or ASCVD)
- Documentation of a supervised diet/exercise program (typically 3–6 months minimum, though this requirement is being challenged as scientifically unsupported)
- A physician attestation that Wegovy is medically necessary
- No history of personal/family medullary thyroid carcinoma or MEN2
- Some plans require trial of an alternative (Qsymia, Contrave, Saxenda) before approving Wegovy
At YourMD, our Concierge plan ($149/month) includes PA support — the physician writes the medical necessity letter, documents the appropriate criteria, and handles appeals if the initial PA is denied. Appeals tend to do better when the medical necessity criteria are properly documented, though approval is never guaranteed.
What If Your Insurance Denies Coverage?
Your options in order of cost-effectiveness:
- Appeal the denial: File a formal appeal with your insurer. Request a peer-to-peer review (your physician speaks directly with the insurer's medical director). This costs you nothing, and a well-documented appeal is sometimes successful.
- NovoCare®: Novo Nordisk offers savings and patient assistance programs for Wegovy®. Eligibility rules and prices change, so see NovoCare for current savings and assistance programs.
- LillyDirect™: For Zepbound® (tirzepatide), Eli Lilly’s direct-to-patient program offers self-pay pricing on single-dose vials. Prices vary by dose and change over time, so check LillyDirect™ for current pricing.
- Compounded semaglutide is not an option: The FDA semaglutide shortage ended in 2025, and compounded copies are generally no longer permitted except for a documented, patient-specific clinical need. YourMD prescribes brand-name medications only. See our article on compounded semaglutide safety for the history.
- Open enrollment strategy: If you know you need GLP-1 therapy, review formulary tiers during open enrollment and choose a plan that covers it — the cost difference in premiums may be less than the out-of-pocket cost of Wegovy without coverage.
Ozempic vs. Wegovy: Insurance Nuance
Ozempic (semaglutide 1 mg) is FDA-approved for type 2 diabetes. Plans that cover diabetes medications but not obesity medications may cover Ozempic if you have T2DM. This is not off-label prescribing — it's prescribing within the approved indication. However, insurers have become increasingly sophisticated about this distinction and may deny Ozempic claims if there is no diabetes diagnosis. Prescribing Ozempic off-label for weight loss without a diabetes diagnosis, primarily to obtain insurance coverage, raises both ethical and clinical documentation concerns. At YourMD we prescribe within appropriate indications and document accordingly.