Wegovy, a popular weight loss medication, has helped many people manage obesity and related health conditions. For UnitedHealthcare members, understanding whether this drug is covered in 2025 is crucial due to its high cost.
This article explains how UnitedHealthcare handles Wegovy coverage, including eligibility, costs, and steps to secure approval. Written in simple language, it provides clear insights for patients and families.
What Is Wegovy and Its Uses?
Wegovy, known as semaglutide, is an injectable medication approved by the FDA for weight loss. It’s designed for adults and children aged 12 and older with obesity or those overweight with health conditions like diabetes or high blood pressure.
The drug mimics a hormone that regulates appetite, helping users feel full longer. It’s typically used alongside a healthy diet and exercise.
Wegovy is also approved to reduce cardiovascular risks, such as heart attacks or strokes, in adults with heart disease and obesity. Its weekly injection schedule makes it convenient for many patients. However, its high cost—around $1,850 per month without insurance—makes coverage a key concern.
UnitedHealthcare’s Approach to Prescription Coverage
UnitedHealthcare, part of UnitedHealth Group, offers a range of insurance plans, including commercial, Medicare, and Medicaid. Their Prescription Drug List (PDL), or formulary, outlines which medications are covered and at what cost.
Wegovy is often listed as a Tier 3 or Tier 4 drug, meaning higher copays or coinsurance. Coverage varies by plan, so checking your specific PDL is essential.
The company requires prior authorization for many high-cost drugs like Wegovy. This process ensures the medication is medically necessary. UnitedHealthcare also offers programs like Real Appeal to support weight management, which may complement Wegovy use.
Is Wegovy Covered by UnitedHealthcare Insurance?
UnitedHealthcare may cover Wegovy for weight loss or cardiovascular risk reduction, but coverage depends on your plan. For weight loss, you typically need a BMI of 30 or higher (obesity) or a BMI of 27 with weight-related conditions like hypertension.
Coverage for heart disease risk reduction applies to adults with obesity or overweight and a history of cardiovascular issues. Prior authorization is usually required.
Some employer-sponsored plans exclude weight loss medications entirely. Medicaid coverage varies by state, and Medicare Part D may cover Wegovy for heart-related uses but not for weight loss. Always verify your plan’s details to confirm eligibility.
Eligibility Criteria for Wegovy Coverage
To qualify for Wegovy coverage, UnitedHealthcare often requires specific conditions to be met. These include:
- BMI Requirements: Adults need a BMI of 30+ or 27+ with conditions like diabetes or high cholesterol.
- Medical Necessity: A doctor must document that Wegovy is essential for your health.
- Lifestyle Changes: You may need to participate in a weight management program, like Real Appeal.
- Prior Authorization: Approval is needed, often requiring proof of failed weight loss attempts.
For cardiovascular risk reduction, a documented heart disease diagnosis is necessary. Coverage for children aged 12 and up requires a BMI in the 95th percentile or higher.
Costs of Wegovy with UnitedHealthcare
Without insurance, Wegovy costs around $1,850 for a 28-day supply. With UnitedHealthcare coverage, costs depend on your plan’s tier and whether you’ve met your deductible.
Copays for Tier 3 or 4 drugs typically range from $50 to $150 per month. Some plans require coinsurance, where you pay a percentage of the drug’s cost.
If coverage is denied, options like the Wegovy Savings Offer from Novo Nordisk can reduce costs to $499 per month for eligible patients. Always check your out-of-pocket costs with UnitedHealthcare’s member services.
Table: Estimated Wegovy Costs with UnitedHealthcare in 2025
| Plan Type | Coverage Status | Estimated Cost |
|---|---|---|
| Commercial (Weight Loss) | Covered with prior auth | $50–$150 copay or coinsurance |
| Commercial (Heart Risk) | Covered with prior auth | $50–$150 copay or coinsurance |
| Medicare Part D | Limited to heart risk | $50–$200, varies by plan |
| Medicaid | Varies by state | $0–$100, depending on state rules |
Prior Authorization Process
UnitedHealthcare often requires prior authorization for Wegovy. Your doctor must submit documentation proving medical necessity, such as your BMI, medical history, or previous weight loss efforts. This process can take several days, so plan ahead for prescriptions. If denied, your doctor can appeal with additional evidence.
Contact UnitedHealthcare’s member services or use the PreCheck MyScript tool on their website to start the process. Keep records of all submissions to track progress. Persistence is key if initial requests are denied.
Challenges with Wegovy Coverage
Securing Wegovy coverage can be challenging due to varying plan policies. Some UnitedHealthcare plans exclude weight loss drugs, especially employer-sponsored ones.
Medicare Part D doesn’t cover Wegovy for weight loss, limiting options for older adults. Medicaid coverage depends on state-specific rules, with only 14 states covering GLP-1 drugs for weight loss as of 2025.
Prior authorization delays can also frustrate patients. If your plan doesn’t cover Wegovy, you may need to explore alternatives or pay out-of-pocket. Discussing options with your doctor can help navigate these hurdles.
Alternatives to Wegovy
If Wegovy isn’t covered, UnitedHealthcare may cover other medications like Saxenda or Mounjaro for weight loss or diabetes management. Ozempic, another semaglutide drug, is often covered for Type 2 diabetes but not weight loss. Each alternative has its own coverage criteria and costs. Check your PDL to see what’s available.
Your doctor can also recommend non-medication options, like UnitedHealthcare’s Real Appeal program, which offers coaching and resources for weight management. Exploring all options ensures you find a suitable solution.
Steps to Confirm Coverage
To find out if Wegovy is covered by UnitedHealthcare insurance, follow these steps:
- Check Your PDL: Log in to myuhc.com or call member services to review your plan’s formulary.
- Contact Member Services: Call the number on your insurance card to confirm coverage and copays.
- Consult Your Doctor: Work with your healthcare provider to submit prior authorization requests.
- Explore Appeals: If denied, ask your doctor to appeal with additional documentation.
Using UnitedHealthcare’s online tools or app can simplify the process. Keep all correspondence for reference.
What to Do If Coverage Is Denied
If UnitedHealthcare denies Wegovy coverage, don’t give up. Your doctor can appeal by providing more medical evidence, such as a detailed history of weight-related conditions. You can also request a tier exception if Wegovy is non-preferred on your plan’s formulary. Novo Nordisk offers a sample letter to request coverage from your employer’s HR department.
Other options include manufacturer savings programs or discount cards like GoodRx. Discuss affordability with your doctor to explore all possibilities.
Legislative Changes and Future Outlook
In 2025, Medicare Part D covers Wegovy for cardiovascular risk reduction but not weight loss. The proposed Treat and Reduce Obesity Act of 2023 could expand Medicare coverage for weight loss drugs if passed. This might influence private insurers like UnitedHealthcare to broaden coverage. For now, coverage remains plan-specific.
As demand for GLP-1 drugs grows, UnitedHealthcare may adjust its policies. Staying informed about legislative changes and plan updates can help you anticipate coverage shifts. Check with UnitedHealthcare regularly for the latest information.
Summary
Determining if Wegovy is covered by UnitedHealthcare insurance in 2025 depends on your specific plan and medical needs. Coverage is available for weight loss or cardiovascular risk reduction with prior authorization, but eligibility criteria like BMI or heart disease history apply.
Costs vary, with copays ranging from $50 to $150 for covered plans. Checking your PDL, working with your doctor, and exploring appeals or savings programs are key to accessing Wegovy affordably.
FAQ
Is Wegovy covered by UnitedHealthcare for weight loss in 2025?
Coverage depends on your plan, but many UnitedHealthcare plans cover Wegovy for weight loss with prior authorization. You typically need a BMI of 30+ or 27+ with weight-related conditions. Check your PDL or contact member services to confirm.
Does UnitedHealthcare cover Wegovy for heart disease?
Yes, Wegovy is often covered for cardiovascular risk reduction in adults with heart disease and obesity or overweight. Prior authorization is required. Copays typically range from $50 to $150, depending on your plan.
What is the cost of Wegovy with UnitedHealthcare?
With coverage, copays for Wegovy range from $50 to $150 per month, depending on your plan’s tier. Without coverage, it costs around $1,850 for a 28-day supply. Savings programs may reduce costs to $499 per month.
What if my UnitedHealthcare plan doesn’t cover Wegovy?
If denied, your doctor can appeal with additional documentation or request a tier exception. You can also use Novo Nordisk’s savings offer or discount cards. Discuss alternatives like Saxenda with your doctor.
Does Medicare or Medicaid cover Wegovy with UnitedHealthcare?
Medicare Part D may cover Wegovy for heart risk reduction, not weight loss. Medicaid coverage varies by state, with 14 states covering GLP-1 drugs for weight loss. Contact your plan administrator for details.