Wegovy (semaglutide) is a breakthrough medication for weight management, sparking interest among Canadians.
Many wonder if Wegovy Canada covered by insurance is a reality, given its high cost. This article explores insurance coverage, eligibility, costs, and how to access Wegovy in Canada.
What Is Wegovy?
Wegovy is a once-weekly injectable medication approved by Health Canada in 2021 for chronic weight management. It mimics the GLP-1 hormone to reduce appetite and promote weight loss.
It’s prescribed for adults with obesity (BMI ≥30) or overweight (BMI ≥27) with conditions like type 2 diabetes or hypertension.
Unlike Ozempic, which treats diabetes, Wegovy is specifically for weight loss. It’s not approved for children under 12 or cosmetic weight loss.
Understanding Insurance in Canada
Canada’s healthcare system includes public plans like OHIP and private insurance through employers or individual plans. Public plans cover essential medical services, but prescription drugs like Wegovy often rely on private coverage. The Canadian Agency for Drugs and Technologies in Health (CADTH) advises public plans on drug reimbursement.
Private insurers, like Sun Life or Manulife, vary in coverage for weight loss drugs. Understanding these systems is key to accessing Wegovy.
Is Wegovy Canada Covered by Insurance?
Wegovy Canada covered by insurance depends on the provider and plan. Some private insurers, like iA Financial Group and Canada Life, cover Wegovy for weight management as of late 2024, often with prior authorization. Public plans, like OHIP or British Columbia’s MSP, generally don’t cover Wegovy due to its classification as a weight loss drug.
Coverage is more likely for those with obesity-related conditions. Check with your insurer for specific plan details.
Public Insurance and Wegovy
Public drug plans in Canada, such as Ontario’s Drug Benefit (ODB) or British Columbia’s PharmaCare, rarely cover weight loss medications. CADTH recommended against public reimbursement for Wegovy in 2022 due to limited long-term data. Recent approvals for cardiovascular benefits may prompt reconsideration, but no provinces currently cover it.
Those under 24 with OHIP+ may access some drugs, but Wegovy is excluded. Public coverage remains limited for now.
Private Insurance Coverage
Private insurers are increasingly covering Wegovy, especially for plans including weight management drugs. For example, iA Financial Group announced coverage starting November 15, 2024, with prior authorization. Sun Life and Canada Life also cover it under specific plans, though Manulife is still reviewing it.
Coverage often requires a BMI ≥30 or ≥27 with comorbidities like diabetes. Contact your insurer to confirm eligibility.
Prior Authorization and Criteria
Most insurers require prior authorization for Wegovy to ensure medical necessity. This involves your doctor submitting forms detailing your BMI, health conditions, and prior weight loss attempts. Some plans mandate step therapy, trying cheaper options like Saxenda first.
Incomplete documentation can delay or deny coverage. Work closely with your healthcare provider to meet criteria.
Costs of Wegovy Without Insurance
Wegovy costs $388.64 for a 28-day supply in Canada, as set by Novo Nordisk. Without insurance, annual costs exceed $4,700, making it unaffordable for many. Pharmacy markups or dispensing fees may increase the price.
Novo Nordisk’s savings card isn’t available for government plan beneficiaries. Private insurance can significantly reduce out-of-pocket costs.
Table: Wegovy Costs and Coverage Options in Canada
| Option | Cost (28 Days) | Notes |
|---|---|---|
| Out-of-Pocket | $388.64–$460 | Varies by pharmacy; no insurance applied. |
| Private Insurance | $0–$100 | Depends on plan; often requires prior authorization. |
| Public Plans | Not covered | OHIP, MSP, etc., do not cover Wegovy. |
| Savings Programs | Limited | Not available for government plan users. |
Note: Costs and coverage vary. Confirm with your insurer or pharmacy.
How to Access Wegovy in Canada
To access Wegovy, consult a licensed healthcare provider, in-person or online through platforms like Felix. They’ll assess your BMI and health to determine eligibility. If approved, they’ll issue a prescription and submit prior authorization forms.
Fill prescriptions at pharmacies like Shoppers Drug Mart or through Express Scripts for mail-order. Ensure all forms are complete to avoid delays.
Steps to Secure Insurance Coverage
Follow these steps to improve coverage chances:
- Consult your doctor to confirm Wegovy’s suitability.
- Gather medical records showing BMI and comorbidities.
- Submit prior authorization forms through your provider.
- Verify coverage with your insurer before filling the prescription.
Clear documentation is critical. Follow up with your insurer if needed.
Appealing a Coverage Denial
If your insurer denies Wegovy coverage, you can appeal. Review the denial letter to understand the reason, such as insufficient medical history. Your doctor can submit additional documentation, like lab results or prior treatment records.
Follow your insurer’s appeal process, often outlined online. Appeals may take weeks, so act promptly.
Wegovy’s Benefits and Side Effects
Wegovy helps users lose 15–20% of body weight on average, improving conditions like diabetes and heart disease. It’s also approved to reduce cardiovascular risks in adults with heart disease and obesity. Common side effects include nausea, diarrhea, and headache.
Serious risks, like pancreatitis or thyroid tumors, are rare. Report symptoms like severe stomach pain to your doctor immediately.
Why Insurers Hesitate to Cover Wegovy
Insurers hesitate due to Wegovy’s high cost and uncertain long-term benefits. Obesity is often viewed as a lifestyle issue, not a chronic disease, limiting coverage. Recent data on cardiovascular benefits may shift perspectives.
Private insurers are more likely to cover Wegovy than public plans. Advocacy for obesity as a chronic condition may expand coverage.
Wegovy and Lifestyle Changes
Wegovy works best with a reduced-calorie diet and increased exercise. Insurers may require proof of lifestyle changes for coverage. TRICARE, for example, mandates nutrition counseling for weight loss drugs.
Discuss lifestyle programs with your doctor. Some insurers cover dietitians or fitness plans to support treatment.
Online Prescriptions for Wegovy
Online platforms like Felix offer consultations with licensed practitioners. After an assessment, they can prescribe Wegovy and coordinate with pharmacies for delivery. The visit fee (around $40) isn’t covered by insurance, but medication may be.
Check if your insurer accepts online prescriptions. This can streamline access to Wegovy.
Wegovy for Specific Groups
Wegovy is approved for adults and children over 12 with obesity or specific health conditions. Those with a history of thyroid cancer or Multiple Endocrine Neoplasia syndrome type 2 should avoid it. Pregnant or breastfeeding individuals are also ineligible.
Consult your doctor to ensure Wegovy is safe. Personalized assessments are crucial.
Long-Term Considerations
Wegovy is a long-term treatment for chronic weight management. Insurers may require ongoing proof of effectiveness, like weight loss progress. Regular doctor visits ensure continued coverage and monitor side effects.
Stay consistent with follow-ups. This supports both health and insurance requirements.
Advocacy for Broader Coverage
Groups like Obesity Canada advocate for public coverage of Wegovy, citing its health benefits. Petitions, like one on Change.org, urge OHIP to include Wegovy. These efforts highlight obesity’s impact on conditions like heart disease.
Broader coverage may emerge as evidence grows. Stay informed about policy changes.
What to Discuss with Your Doctor
Before starting Wegovy, share your medical history, including BMI and health conditions. Discuss prior weight loss attempts and insurance requirements. Ask about side effects and how to manage them.
Your doctor can guide you through the coverage process. Clear communication prevents delays.
Summary
Wegovy Canada covered by insurance is possible through some private plans, like iA Financial Group and Canada Life, but not public plans like OHIP.
Coverage requires prior authorization and meeting criteria like a BMI ≥30. Costs range from $0–$100 with insurance, or $388.64–$460 out-of-pocket. Consult your doctor, verify coverage, and appeal denials to access Wegovy affordably.
FAQ Section
Is Wegovy Canada covered by insurance?
Some private insurers, like iA Financial Group and Canada Life, cover Wegovy with prior authorization. Public plans like OHIP don’t cover it. Check with your insurer for details.
How much does Wegovy cost in Canada?
Wegovy costs $388.64–$460 for a 28-day supply without insurance. Private insurance may reduce costs to $0–$100. Costs vary by pharmacy and plan.
What are the requirements for Wegovy coverage?
Insurers require a BMI ≥30 or ≥27 with conditions like diabetes. Prior authorization and step therapy are often needed. Your doctor must submit documentation.
What if my insurance denies Wegovy coverage?
Appeal by submitting additional medical records through your doctor. Follow your insurer’s appeal process. Secondary insurance or savings programs may help.
Are there side effects of Wegovy to consider?
Common side effects include nausea and diarrhea; serious risks like pancreatitis are rare. Report severe symptoms to your doctor. Regular monitoring ensures safe use.