Wegovy, a popular weight-loss medication, has transformed lives, but coverage can be tricky. If you’re wondering, does Express Scripts cover Wegovy, the answer depends on your plan. This article explains Express Scripts’ coverage policies, how to check eligibility, and steps to access Wegovy, using simple language for clarity.
What Is Wegovy?
Wegovy is a brand-name drug containing semaglutide, a GLP-1 receptor agonist. It’s injected weekly to help adults and some children lose weight. The FDA approves it for obesity or overweight with related health issues like diabetes.
Clinical trials show users lose 15% of body weight on average over 68 weeks. Its effectiveness makes coverage a key concern. Understanding if Express Scripts covers Wegovy is the first step.
Express Scripts Overview
Express Scripts is one of the largest pharmacy benefit managers in the U.S. It manages prescription drug coverage for millions through employer, individual, and government plans. Coverage for medications like Wegovy varies by plan formulary.
Express Scripts works with insurers to balance cost and access. To find out does Express Scripts cover Wegovy, you need to review your specific plan. This ensures accurate information.
Does Express Scripts Cover Wegovy?
Express Scripts may cover Wegovy, but it depends on your insurance plan. Many plans cover GLP-1 medications like Wegovy for weight loss if FDA criteria are met, such as a BMI of 30 or higher. However, some plans exclude weight-loss drugs or require step therapy.
Coverage often requires prior authorization to confirm medical necessity. Since 2024, some plans cover Wegovy for cardiovascular benefits too. Checking your plan’s formulary answers does Express Scripts cover Wegovy.
Eligibility for Wegovy Coverage
To qualify for Wegovy coverage, you typically need a BMI of 30 or higher, or 27 with conditions like hypertension or type 2 diabetes. Children 12 and older with a BMI in the 95th percentile may also be eligible. Your doctor must document these criteria.
Express Scripts often requires prior authorization, including lab results or health records. Meeting these standards is crucial to determine if Express Scripts covers Wegovy. Your healthcare provider guides this process.
How to Check Coverage
Start by logging into your Express Scripts account to view your plan’s formulary. Use the “Price a Medication” or “Check Coverage” tools to see if Wegovy is included. You can also call Express Scripts at (800) 467-2006 for details.
Your employer or benefits manager can clarify plan-specific rules. Novo Nordisk’s Wegovy.com offers a coverage checker tool. These steps confirm does Express Scripts cover Wegovy for you.
Prior Authorization Process
Prior authorization is often required for Wegovy. Your doctor submits a form to Express Scripts, detailing your BMI, health conditions, and medical necessity. This process can take days to two weeks.
Express Scripts reviews the request and notifies you of approval or denial. If approved, you can fill your prescription. This step is key to answering does Express Scripts cover Wegovy.
Steps for Prior Authorization
- Consult your doctor to confirm Wegovy eligibility.
- Provide medical records, like BMI and lab results.
- Have your doctor submit the prior authorization form.
- Follow up with Express Scripts for status updates.
Table: Wegovy Coverage by Plan Type
| Plan Type | Wegovy Coverage | Notes |
|---|---|---|
| Employer-Sponsored | Varies; often requires prior authorization | Employer may opt out of weight-loss coverage |
| Individual Plans | Limited, needs prior authorization | Check formulary for inclusion |
| Medicare Plans | No coverage for weight loss | May cover for cardiovascular use |
| Medicaid Plans | Varies by state, often restrictive | Contact Express Scripts for state rules |
Costs with Express Scripts Coverage
Without insurance, Wegovy costs around $1,300 per month. If Express Scripts covers Wegovy, you may pay a copay or coinsurance, ranging from $25 to a percentage of the drug’s cost. Your plan’s drug tier determines the amount.
Novo Nordisk offers a savings card, reducing costs to $500 or less for eligible patients. GoodRx or SingleCare discounts can also help. These options ease the financial burden if Express Scripts covers Wegovy.
What If Coverage Is Denied?
If Express Scripts denies Wegovy coverage, review the denial letter for the reason. Common reasons include weight-loss exclusions, missing prior authorization, or incomplete medical records. Your doctor can appeal with additional evidence.
Appeals have a 39–59% success rate, as real doctors review them, not computers. If denied, explore alternatives like Saxenda or Mounjaro. This helps if Express Scripts doesn’t cover Wegovy.
Appealing a Denial
To appeal, your doctor submits a formal letter to Express Scripts, explaining why Wegovy is medically necessary. Include updated records, like failed diet attempts or health risks. The process can take weeks but often succeeds.
Services like Honest Care can draft appeal letters for you. Community forums like Reddit’s r/WegovyWeightLoss share success stories of overturned denials. Persistence is key when Express Scripts doesn’t cover Wegovy initially.
Medicare and Medicaid Limitations
Medicare plans through Express Scripts do not cover Wegovy for weight loss due to federal rules. However, coverage may apply for cardiovascular benefits with prior authorization. Check with Express Scripts for details.
Medicaid coverage varies by state, often requiring strict criteria. Some states exclude weight-loss drugs entirely. Confirming does Express Scripts cover Wegovy under these plans requires contacting customer service.
Coverage for Cardiovascular Use
Since 2024, the FDA approves Wegovy for reducing cardiovascular risks in patients with heart disease and obesity. Express Scripts covers it for this use in many plans, requiring prior authorization. Your doctor must submit evidence of heart conditions.
This expanded approval broadens access for some users. It’s a new factor in whether Express Scripts covers Wegovy. Verify eligibility with your plan’s formulary.
Express Scripts’ Weight Management Program
Express Scripts offers a weight management program to support health goals. It includes coaching and lifestyle tips but doesn’t guarantee Wegovy coverage. Access to GLP-1 drugs like Wegovy depends on your plan’s formulary.
Some Reddit users report confusion about the program’s requirements, like BMI reviews. Contact Express Scripts to clarify how this program affects whether Wegovy is covered. It’s a useful resource but plan-specific.
Novo Nordisk’s Support
Novo Nordisk’s WeGoTogether program provides resources for Wegovy users. It includes insurance support, a coverage checker, and a sample letter to request employer coverage. Visit Wegovy.com for tools.
Call 1-833-4-WEGOVY for help navigating Express Scripts’ process. These resources assist in confirming does Express Scripts cover Wegovy. They also guide appeals or savings options.
Community Experiences
Reddit’s r/WegovyWeightLoss community shares Express Scripts coverage stories. Some users report approvals with high BMIs, paying $25–$50 monthly. Others faced denials due to employer opt-outs, requiring appeals.
These insights highlight coverage variability. Joining forums offers tips and support. Real-world experiences clarify does Express Scripts cover Wegovy for different plans.
Tips for Success
Work closely with your doctor to meet prior authorization criteria. Submit complete records, including BMI and health history, to avoid delays. Check your formulary annually for updates.
Use Novo Nordisk’s savings card if copays are high. Staying proactive ensures you maximize the chance that Express Scripts covers Wegovy. Persistence pays off.
Long-Term Considerations
Wegovy is often used long-term to maintain weight loss. Express Scripts may require periodic re-authorization to continue coverage. Monitor your plan for changes, as formularies update yearly.
Discuss long-term costs and benefits with your doctor. Understanding does Express Scripts cover Wegovy over time helps you plan. Regular check-ins keep your treatment on track.
Summary
Does Express Scripts cover Wegovy? It depends on your plan, with coverage varying based on formulary, prior authorization, and employer policies.
Eligible users need a BMI of 30 or higher, or 27 with health issues, and often face prior authorization. Check your plan’s formulary, contact Express Scripts, and appeal denials with your doctor’s help.
Novo Nordisk’s savings programs and community insights ease access, ensuring you can navigate coverage and achieve your weight-loss goals.
FAQ
Does Express Scripts cover Wegovy for weight loss?
Coverage depends on your plan; many cover Wegovy with prior authorization for a BMI of 30 or higher. Check your formulary or call (800) 467-2006. Some plans exclude weight-loss drugs.
What is prior authorization for Wegovy?
Your doctor submits a form proving medical necessity, like BMI or health conditions. Express Scripts reviews it, taking days to weeks. It’s required for most Wegovy coverage.
What if Express Scripts denies Wegovy coverage?
Review the denial letter and appeal with your doctor’s support, adding medical evidence. Appeals have a 39–59% success rate. Explore alternatives like Saxenda if denied.
How much does Wegovy cost with Express Scripts?
With coverage, copays range from $25 to a percentage of the $1,300 monthly cost. Novo Nordisk’s savings card can lower costs. Check your plan’s drug tier for specifics.
Does Express Scripts cover Wegovy for heart conditions?
Since 2024, many plans cover Wegovy for cardiovascular risk reduction with prior authorization. Confirm with Express Scripts. It requires proof of heart disease and obesity.