Insurance Coverage for Wegovy (Semaglutide) Oral Tablets for Weight Loss
Critical Clarification: Wegovy is NOT Available as an Oral Tablet
Wegovy (semaglutide 2.4 mg) is only available as a once-weekly subcutaneous injection, not as an oral tablet. 1, 2, 3 The confusion likely stems from the existence of oral semaglutide (Rybelsus), which is FDA-approved exclusively for type 2 diabetes treatment at doses of 3 mg, 7 mg, or 14 mg daily—not for weight loss. 1, 4
FDA-Approved Formulations of Semaglutide
Injectable semaglutide 2.4 mg (Wegovy): FDA-approved for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea). 5, 1, 2
Oral semaglutide (Rybelsus): FDA-approved only for type 2 diabetes management, not for obesity treatment. 1, 4 Oral semaglutide is "less potent" than injectable formulations for weight management and lacks sufficient evidence for weight loss indications. 1
Insurance Coverage Landscape for Wegovy (Injectable)
General Coverage Challenges
Insurance coverage for Wegovy remains a significant barrier to access, with many commercial and government payers denying or restricting coverage for obesity pharmacotherapy. 3 The medication costs approximately $1,557-$1,600 per 30-day supply without insurance. 1
Coverage Criteria When Available
When insurers do cover Wegovy, they typically require:
BMI documentation: BMI ≥30 kg/m² or BMI ≥27 kg/m² with documented weight-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, obstructive sleep apnea). 5, 1
Failed lifestyle modifications: Documentation of previous attempts at diet and exercise for weight loss over 3-6 months. 1
Concurrent lifestyle intervention: Commitment to reduced-calorie diet and increased physical activity (minimum 150 minutes/week). 5, 1
Prior authorization: Most insurers require extensive prior authorization documentation, including medical necessity justification. 1
Medicare and Medicaid Coverage
Medicare Part D explicitly excludes coverage for weight loss medications under current federal law, regardless of medical necessity. This prohibition has been in place since the Medicare Modernization Act of 2003. Medicaid coverage varies dramatically by state, with most states providing limited or no coverage for obesity pharmacotherapy. 1
Commercial Insurance Variability
Coverage among commercial insurers is highly variable and plan-specific. Some employer-sponsored plans explicitly exclude obesity medications, while others may cover them with high cost-sharing requirements or restrictive prior authorization criteria. 1, 3
Critical Pitfalls to Avoid
Do not prescribe oral semaglutide (Rybelsus) for weight loss, as it is not FDA-approved for this indication and will not be covered by insurance for obesity management. 1, 4
Do not assume insurance coverage exists without verifying specific plan benefits, as "clinical utilization of subcutaneous semaglutide will be determined, as insurance coverage will be a limitation for this new medication." 3
Do not prescribe Wegovy without documenting failed lifestyle interventions, as this is typically required for any potential insurance authorization. 1
Practical Recommendations
For patients seeking semaglutide for weight loss, prescribe injectable Wegovy 2.4 mg weekly, not oral semaglutide. 1, 2 Contact the patient's specific insurance plan to verify coverage before prescribing, as coverage policies change frequently and vary significantly between plans. 3 Consider enrollment in the WeGoTogether patient support program, which may provide resources for navigating insurance authorization and financial assistance options. 6
Guideline societies recommend that payors should cover evidence-based obesity treatments to reduce barriers to treatment access, though this recommendation has not translated into widespread coverage. 5, 1