Cigna Wegovy Prior Authorization and Weight Loss Coverage

Cigna requires prior authorization for Wegovy, a prescription medication for weight loss.

Cigna covers Wegovy for eligible members, but you'll need to meet specific requirements to get coverage.

If you're prescribed Wegovy, your doctor will need to submit a prior authorization request to Cigna to confirm coverage.

This process typically takes 1-3 business days, and your doctor's office will be notified once the request is approved.

Cigna typically requires prior authorization for Wegovy, which means you'll need to work with your healthcare provider to submit paperwork to Cigna demonstrating that Wegovy is medically necessary before the insurance company will cover the medication.

To initiate the prior authorization process, your healthcare provider will need to document that you meet all of the following requirements: you are at least 18 years old, you have been making lifestyle changes, including a reduced-calorie diet, to lose weight for at least 3 months, you either have a body mass index (BMI) of 30 or above, or you have a BMI of 27 or above and a weight-related health condition, and you plan to use Wegovy in addition with lifestyle changes.

Your healthcare provider will also need to show that you've lost at least 5% of your body weight since starting treatment with Wegovy to continue getting prescription coverage for up to 12 months.

Here are the specific requirements for prior authorization for Wegovy:

Cigna may deny a prior authorization request for Wegovy if you're already taking another weight loss medication, and Wegovy shouldn't be used at the same time as other injections or pills for weight loss.

If you're taking Wegovy, you'll likely need to get prior authorization from Cigna, which means your healthcare provider will need to submit paperwork to demonstrate that the medication is medically necessary.

Cigna requires you to meet certain criteria, including being at least 18 years old, making lifestyle changes like a reduced-calorie diet for at least three months, and having a body mass index (BMI) of 30 or above, or a BMI of 27 or above with a weight-related health condition.

To get prior authorization, your healthcare provider will need to document that you meet all of these requirements, which include making lifestyle changes, having a certain BMI, and planning to use Wegovy in addition to lifestyle changes.

If you meet these requirements, Cigna may approve your prior authorization for up to seven months, but you'll need to resubmit for prior authorization again to continue getting prescription coverage for Wegovy.

To resubmit, you'll need to show that you still meet all four of the requirements above, plus one additional requirement: that you've lost at least 5% of your body weight since starting treatment with Wegovy.

Here are the specific requirements you'll need to meet for prior authorization:

If you meet these requirements, Cigna may approve your prior authorization for up to 12 months.

If Cigna won't cover Wegovy, you'll have to pay out-of-pocket for your prescription, which can be costly - a 28-day supply costs $1,349.02 without insurance.

You can ask your healthcare provider if another weight loss medication could be a good fit for you, as some may be covered by your plan or be more affordable.

Zepbound (tirzepatide) is a weight loss injection that costs $1,059.87 for a 28-day supply without insurance.

Some Cigna plans do cover oral appetite suppressants, such as Qsymia, Contrave, or Xenical, which might be an alternative option.

If you're unable to get Cigna to cover Wegovy, you'll need to pay the full cost of the medication until you can resubmit for prior authorization again.

Here's a comparison of the cost of Wegovy and Zepbound without insurance:

Cigna's coverage of weight-loss drugs can be a bit tricky to navigate. Cigna's national plan lists Zepbound and Wegovy as "excluded drugs" and Mounjaro and Ozempic as "not covered", but these drugs are still included in Cigna's formulary.

You might be wondering if there's any wiggle room for coverage. According to Roy Moore, a senior healthcare research and data analyst, these drugs are usually included as tier-4 (nonpreferred) drugs, which means they require prior authorization for coverage.

If you're looking for other weight-loss options, you might want to consider the following drugs that are covered by Cigna: Contrave, Adipex-P, and Qsymia. These medications meet certain criteria requirements for medically necessary drugs.

Here's a quick rundown of these covered medications:

Keep in mind that coverage requirements may vary depending on your individual plan.