Understanding health insurance coverage for medications can feel overwhelming. If you’re a TRICARE beneficiary wondering about weight loss drugs like Wegovy, you’re not alone.
This article explains TRICARE’s coverage for Wegovy in simple terms. It covers eligibility, requirements, costs, and more for 2025.
What Is Wegovy?
Wegovy is a prescription medication used for chronic weight management. It contains semaglutide, a GLP-1 receptor agonist that helps reduce appetite.
The FDA has approved it for adults and some children with obesity or weight-related health issues. It’s taken as a weekly injection alongside a reduced-calorie diet and exercise.
Wegovy is also approved to lower cardiovascular risks in adults with heart disease. This makes it a versatile drug for specific health needs. It’s not a quick fix but part of a long-term health plan. Always consult your doctor before starting it.
TRICARE’s Prescription Drug Coverage
TRICARE provides prescription drug coverage for most beneficiaries. This includes active-duty members, retirees, and their families.
The TRICARE Formulary lists all covered medications, including brand-name and generic drugs. Wegovy is part of this formulary, but specific rules apply.
TRICARE covers drugs approved by the FDA. Coverage depends on the drug’s purpose and medical necessity. For weight loss medications, TRICARE has strict criteria. These ensure the drug is appropriate for the patient’s condition.
Does TRICARE Cover Wegovy for Weight Loss?
TRICARE covers Wegovy for chronic weight management under certain conditions. It’s one of the few weight loss drugs included in the formulary. To qualify, beneficiaries must meet specific health criteria. A licensed provider must also prescribe it.
Coverage isn’t automatic. TRICARE requires prior authorization for Wegovy. This means your doctor must submit a form proving the drug is medically necessary. Without this, TRICARE won’t cover the cost.
Eligibility Criteria for Wegovy Coverage
To get Wegovy covered by TRICARE, you must meet these requirements:
- Have a BMI of 30 or higher (obesity), or a BMI of 27 or higher with conditions like hypertension or sleep apnea.
- Have tried behavioral modification and a reduced-calorie diet for at least six months without success.
- Have attempted other FDA-approved weight loss drugs first, unless contraindicated.
Your doctor must document these criteria. You also need to stay on a diet and exercise plan while using Wegovy.
Prior Authorization and Step Therapy
TRICARE uses step therapy for weight loss drugs like Wegovy. This means you must try less expensive medications first.
Examples include drugs like phentermine or orlistat. If these don’t work or aren’t suitable, TRICARE may approve Wegovy.
A prior authorization form is mandatory. Your doctor fills it out and submits it to TRICARE. The form shows why Wegovy is needed and confirms you’ve met the criteria. Approval can take a few days to weeks.
How Much Does Wegovy Cost with TRICARE?
Wegovy’s cost depends on where you fill the prescription. TRICARE’s pharmacy program includes military pharmacies, retail pharmacies, and home delivery. Costs are lowest at military pharmacies and through home delivery.
For a 90-day supply via TRICARE Pharmacy Home Delivery, the copay is $38 for Wegovy. Retail pharmacies may have higher copays, around $60-$80 for 30 days. These costs apply to most beneficiaries as of 2025.
Here’s a quick look at Wegovy copays:
| Pharmacy Type | Copay for 90-Day Supply | Notes |
|---|---|---|
| Military Pharmacy | $0 | Free for most beneficiaries |
| TRICARE Home Delivery | $38 | Most cost-effective for non-military |
| Retail Network Pharmacy | $60-$80 (30 days) | Varies by plan and location |
Always check with your pharmacy for exact costs.
Wegovy for Other Conditions
TRICARE covers Wegovy not only for weight loss but also for reducing cardiovascular risks. This applies to adults with known heart disease and obesity or overweight. The same prior authorization process is required. Your doctor must justify its use for this purpose.
Wegovy isn’t covered for off-label uses, like weight loss without meeting BMI criteria. TRICARE strictly follows FDA-approved indications. Always discuss your goals with your healthcare provider.
Comparing Wegovy to Other Medications
TRICARE also covers Zepbound, another weight loss drug, under similar rules. Zepbound has the same $38 copay for a 90-day supply via home delivery. Other drugs, like Ozempic and Mounjaro, are covered only for type 2 diabetes, not weight loss. These require separate prior authorization.
Trying cheaper drugs first is part of TRICARE’s step therapy. If you’ve used other diabetes or weight loss drugs in the past 720 days, you may skip some steps. Check the TRICARE Formulary Search Tool for details.
How to Get Wegovy Covered
To get Wegovy covered, follow these steps:
- Visit a licensed healthcare provider to discuss your weight loss needs.
- Confirm you meet TRICARE’s eligibility criteria (BMI, prior treatments).
- Have your doctor submit a prior authorization form.
- Choose a pharmacy option (military, home delivery, or retail).
- Stay on a diet and exercise plan as required.
Your provider can help with paperwork. Contact your regional TRICARE office if you face issues.
Where to Fill Your Wegovy Prescription
TRICARE offers three main ways to get prescriptions:
- Military Pharmacies: Free for most beneficiaries, but availability may vary.
- TRICARE Pharmacy Home Delivery: Convenient and cost-effective at $38 for 90 days.
- Retail Network Pharmacies: More expensive but widely available.
Home delivery is often the best choice for Wegovy. It ensures a steady supply and lower costs. Check with Express Scripts for home delivery setup.
What If TRICARE Denies Coverage?
If TRICARE denies your Wegovy coverage, don’t panic. Your doctor can appeal the decision. They may need to provide more medical evidence or try alternative drugs. You can also contact TRICARE’s customer service for clarification.
Another option is exploring manufacturer discounts. Novo Nordisk offers a $25 copay card for Wegovy, but it’s not available for TRICARE beneficiaries. Always confirm with your provider or pharmacy.
Tips for Managing Weight with TRICARE
TRICARE supports weight management beyond medications. Beneficiaries can access dietitians and health coaches through military treatment facilities. Behavioral modification programs are often required alongside Wegovy. These services help you stay on track.
Lifestyle changes are key. Combine Wegovy with a balanced diet and regular exercise. Your doctor can guide you on sustainable habits.
Wegovy’s Safety and Side Effects
Wegovy is generally safe but has potential side effects. Common ones include nausea, diarrhea, and stomach pain. Serious risks include pancreatitis or thyroid tumors. Always discuss these with your doctor.
TRICARE requires your provider to monitor your health while on Wegovy. Report any unusual symptoms immediately. Never use Wegovy if you have a history of certain thyroid cancers or MEN 2.
Updates for 2025
TRICARE’s coverage rules for 2025 remain consistent for Wegovy. The open season (November 11 to December 10, 2024) allows changes to your plan. Ensure your DEERS information is updated to avoid coverage issues. No major policy changes affect Wegovy coverage this year.
Check the TRICARE website for updates. Policies can evolve based on FDA approvals or cost considerations. Staying informed helps you plan.
Summary
TRICARE covers Wegovy for weight management and cardiovascular risk reduction, but strict criteria apply. You need a BMI of 30 (or 27 with health issues), prior authorization, and step therapy.
Copays are reasonable, especially via home delivery ($38 for 90 days). Work closely with your doctor to meet requirements and explore TRICARE’s support services for weight management. Always check the TRICARE Formulary Search Tool for the latest details.
FAQ
Does TRICARE cover Wegovy for everyone?
TRICARE covers Wegovy for beneficiaries meeting specific criteria, like a BMI of 30 or higher (or 27 with conditions). Prior authorization and step therapy are required. Consult your doctor to confirm eligibility.
How much is the copay for Wegovy with TRICARE?
For a 90-day supply, the copay is $38 via TRICARE Pharmacy Home Delivery. Military pharmacies may offer it for free. Retail pharmacies cost more, around $60-$80 for 30 days.
Can I use Wegovy for diabetes with TRICARE?
Wegovy is not approved for diabetes; TRICARE covers it for weight loss or cardiovascular risk reduction. For diabetes, drugs like Ozempic or Mounjaro are covered with prior authorization.
What if I don’t qualify for Wegovy coverage?
If TRICARE denies coverage, your doctor can appeal or suggest alternative drugs. You can also explore TRICARE’s dietitian services or other weight loss programs.
Where can I check if Wegovy is covered?
Use the TRICARE Formulary Search Tool online to check coverage and required forms. Contact your regional TRICARE office or provider for assistance.