Priority Health offers a variety of health insurance plans in Michigan, including commercial individual and group coverage, Medicare Advantage, and Medicaid options. These plans help members access prescription medications through carefully managed formularies. Wegovy (semaglutide) stands out as a leading injectable for chronic weight management and cardiovascular risk reduction.
Many people turn to Wegovy because of its strong results in supporting weight loss and improving heart health when combined with diet and exercise. The medication’s high cost without coverage often prompts questions about insurance support. Priority Health follows specific rules based on plan type and federal or state guidelines.
In 2026, coverage for GLP-1 medications like Wegovy continues to evolve with new restrictions in some programs and potential expansions elsewhere. This guide provides clear information on how to check eligibility, understand requirements, and explore alternatives if needed.
What Is Wegovy and Its Main Uses?
Wegovy is a once-weekly injection containing semaglutide, a GLP-1 receptor agonist. It helps regulate appetite, slow digestion, and promote feelings of fullness. The FDA approves it for long-term weight management in adults with obesity (BMI 30 or higher) or overweight (BMI 27+) plus at least one weight-related condition.
In 2024, Wegovy also earned approval to reduce the risk of major cardiovascular events in adults with established heart disease who are overweight or obese. This additional indication plays a key role in coverage decisions. Doctors prescribe it alongside lifestyle changes for sustained benefits.
Without insurance, a monthly supply typically costs $1,300 or more. Coverage through plans like Priority Health can lower this significantly when criteria are met.
Does Priority Health Cover Wegovy?
Priority Health coverage for Wegovy varies significantly by plan type and medical indication. For commercial individual, group, or employer-sponsored plans, coverage is often possible with prior authorization when medical necessity is demonstrated, such as meeting BMI thresholds and having weight-related comorbidities. Some plans include enhanced weight-loss riders that specifically cover Wegovy for obesity management, though these are usually limited to self-funded employer groups.
For Priority Health Medicare Advantage plans, federal Medicare Part D rules generally exclude coverage for drugs used solely for weight loss. Wegovy may be covered if prescribed for its FDA-approved cardiovascular risk reduction indication in patients with documented heart disease and obesity/overweight status, subject to the plan’s 2026 formulary, prior authorization, and other utilization management tools.
In Michigan Medicaid plans administered by Priority Health, coverage for Wegovy and similar GLP-1 weight-loss drugs became more restrictive starting January 1, 2026. New criteria apply, often requiring non-weight-loss indications like cardiovascular risk reduction or severe obstructive sleep apnea, with prior authorization mandatory for all uses.
Real-world reports show mixed experiences. Some members secure approval with low copays after submitting documentation, while others face denials or step therapy requirements. Always verify your specific plan’s Approved Drug List for the most accurate 2026 information.
How to Check and Secure Coverage for Wegovy: Step-by-Step Breakdown
Step 1: Review Your Plan Type and Formulary
Log into your Priority Health member portal or call Customer Service. Use the online Approved Drug List tool to search for “semaglutide” or “Wegovy.” Note the tier, any prior authorization needs, step therapy, or quantity limits listed for your plan in 2026.
Step 2: Confirm Your Medical Indication
Work with your doctor to ensure the prescription aligns with covered uses. For weight management, document BMI (30+ or 27+ with conditions like hypertension) and failed prior attempts at diet/exercise. For cardiovascular protection, provide evidence of heart disease.
Step 3: Complete Prior Authorization Process
Your healthcare provider submits the request electronically or via fax, including supporting records like lab results, medical history, and rationale. Priority Health reviews for medical necessity. Track the status and respond quickly to any requests for additional information.
Step 4: Understand Costs and Appeals
If approved, pay deductibles, copays, or coinsurance based on your plan’s tier. If denied, appeal with more documentation. Manufacturer savings programs can help bridge gaps.
Factors That Influence Wegovy Coverage Decisions
Prior authorization is standard for specialty medications like Wegovy. Plans may require proof of step therapy, such as trying lower-cost options or documented lifestyle interventions first. Quantity limits and age restrictions sometimes apply.
Employer-specific riders affect commercial plans. Self-funded groups have more flexibility to add enhanced coverage for weight-loss GLP-1s. Medicare Advantage follows strict federal exclusions for pure weight loss.
Medicaid changes in 2026 tighten criteria, focusing on non-weight-loss indications. Ongoing national discussions about GLP-1 pilots in Medicare may influence future access, but as of early 2026, standard rules apply.
Comparison of Wegovy Coverage Across Priority Health Plan Types
Coverage patterns help clarify options. Here’s a table summarizing typical approaches for Wegovy and similar medications in 2026:
| Plan Type | Primary Coverage for Weight Management | Coverage for CV Risk Reduction | Common Requirements |
|---|---|---|---|
| Commercial/Group | Often with PA; possible via rider | Likely covered | BMI documentation, prior attempts, PA |
| Medicare Advantage | Not covered for weight loss alone | Possible with PA | Heart disease proof, formulary placement |
| Michigan Medicaid | More restrictive since Jan 2026 | Covered with new criteria | PA required, non-weight indications |
| Enhanced Weight-Loss Rider | Available for select self-funded groups | N/A | Group-specific; medical necessity |
These reflect general trends from current policies. Exact details vary—check your formulary directly.
Costs and Out-of-Pocket Expenses When Covered
Approved coverage reduces expenses considerably. Copays often fall between $25 and $100 per month, depending on tier and deductible status. Specialty tiers may involve higher coinsurance initially.
Novo Nordisk’s savings card helps eligible commercially insured patients pay as little as $25 monthly. Cash-pay discounts or pharmacy programs offer $199–$349 options for introductory periods in 2026.
Without coverage, full costs remain high. Patient assistance foundations support those who qualify based on income.
What to Do If Coverage Is Denied
Submit an appeal with additional medical evidence from your doctor. Highlight ongoing need, progress, and adherence to requirements. Priority Health provides appeal processes through Member Services.
Explore manufacturer programs or alternative GLP-1 medications like Ozempic (for diabetes) that may have easier placement. Discuss switches with your provider.
Stay informed during open enrollment periods. Plans update annually, and new policies could improve access.
Manufacturer Savings and Assistance Programs
NovoCare offers robust support for Wegovy. Eligible patients access significant discounts or free medication in some cases. Apply online or through your doctor.
Pharmacy discount cards provide temporary relief. Foundations help uninsured or underinsured individuals.
Track national changes. Potential Medicare pilots starting mid-2026 may expand GLP-1 access gradually.
Summary
Does Priority Health cover Wegovy? Coverage depends heavily on your plan type and the prescribed indication. Commercial plans often approve with prior authorization for weight management when medical criteria are met, while Medicare Advantage limits it to cardiovascular risk reduction. Medicaid became more restrictive in 2026, requiring non-weight-loss uses and prior authorization.
Prior authorization, documentation, and formulary checks are essential steps. Costs drop substantially when approved, with manufacturer savings adding further help. Contact Priority Health or your provider to confirm 2026 details for your specific plan. This ensures you access the treatment safely and affordably.
FAQ
Does Priority Health cover Wegovy for weight loss?
Coverage varies by plan. Many commercial plans may cover it with prior authorization if you meet BMI criteria (30+ or 27+ with comorbidities) and show medical necessity. Some employer groups offer enhanced riders. Medicare and Medicaid generally exclude or restrict it for weight loss alone.
Can Priority Health Medicare Advantage cover Wegovy?
Medicare Part D excludes coverage for weight loss. It may cover Wegovy for cardiovascular risk reduction in patients with heart disease and obesity/overweight. Prior authorization is required—check your 2026 formulary for placement.
What requirements does Priority Health need for Wegovy approval?
Plans typically require prior authorization, documented BMI, history of failed weight loss efforts, and medical necessity. For CV indications, proof of heart disease is key. Your doctor submits supporting records.
How much does Wegovy cost with Priority Health coverage?
When approved, copays range from $25–$100 monthly, or coinsurance applies after deductibles. Manufacturer savings can reduce it to $25 or less for eligible commercial members. Full price without coverage exceeds $1,300 per month.
What if Priority Health denies coverage for Wegovy?
Appeal with additional documentation. Use Novo Nordisk savings programs, patient assistance, or cash-pay discounts. Consider alternatives like diabetes-focused GLP-1s if suitable. Consult your doctor for the best path forward.