Wegovy has emerged as a leading option for chronic weight management. This semaglutide-based injection helps adults with obesity or overweight conditions achieve meaningful weight loss when combined with diet and exercise. For many, it offers a path to better health and reduced risks for related conditions like heart disease.
Navigating insurance coverage can add complexity, especially with pharmacy benefit managers like CVS Caremark. As of 2025, Wegovy holds a preferred status on many CVS Caremark formularies, making it more accessible than some alternatives. Yet, prior authorization remains a key step to ensure approval.
This guide breaks down the process in simple terms, helping patients and providers understand requirements and streamline submissions. We’ll cover eligibility, steps, and tips to avoid delays, all while keeping things straightforward and actionable.
Understanding Wegovy and Its Benefits
Wegovy works by mimicking the GLP-1 hormone, which regulates appetite and blood sugar. Administered weekly via injection, it starts at a low dose and ramps up to 2.4 mg. Clinical trials show users can lose up to 15% of body weight over a year.
It’s FDA-approved for adults with a BMI of 30 or higher, or 27 or higher with weight-related comorbidities like hypertension or type 2 diabetes. Beyond weight loss, it reduces cardiovascular risks in those with established heart disease.
For CVS Caremark members, Wegovy’s preferred placement on formularies since July 2025 simplifies access compared to non-preferred options. However, prior authorization confirms medical necessity and adherence to plan rules.
What Is CVS Caremark and Prior Authorization?
CVS Caremark manages prescription benefits for millions through employer and health plans. It designs formularies to balance cost, safety, and effectiveness, often placing drugs like Wegovy in preferred tiers for lower copays.
Prior authorization, or PA, is a review process where your doctor submits details to verify the drug fits your needs. It’s common for high-cost medications to prevent overuse and ensure appropriate prescribing.
For Wegovy, PA helps CVS Caremark confirm FDA indications and plan-specific criteria. Approvals typically last 6-12 months, with renewals requiring progress documentation like weight loss records.
Wegovy Prior Authorization Criteria CVS Caremark
CVS Caremark’s criteria for Wegovy align closely with FDA labeling while incorporating plan safeguards like step therapy. Initial approval requires proof of obesity or overweight with comorbidities, plus lifestyle efforts. Quantity limits cap doses at standard levels, with overrides possible for medical reasons.
Renewals focus on sustained benefits, such as at least 5% weight loss after three months. As the preferred GLP-1 for obesity in 2025 formularies, Wegovy faces fewer hurdles than alternatives like tirzepatide products.
Confirm Eligibility Basics
Start by verifying your BMI and health status. CVS Caremark requires documentation of BMI ≥30 kg/m², or ≥27 kg/m² with conditions like dyslipidemia or sleep apnea. Include recent weight history and failed attempts at lifestyle changes alone.
Your prescriber must note how Wegovy fits as an adjunct therapy. Labs or comorbidities strengthen the case, showing medical necessity beyond cosmetic goals.
Document Prior Therapies
Step therapy often applies, mandating trials of lower-cost options. CVS Caremark typically requires 3 months of a preferred oral weight loss drug, like phentermine, or another GLP-1 if applicable. Provide pharmacy records or prescriber notes on intolerance or failure.
For those with cardiovascular indications, emphasize risk reduction potential. This can bypass some steps if heart disease documentation is robust.
Submit Required Forms
Use CVS Caremark’s PA form, available online or via fax. Include ICD-10 codes for obesity (E66.01) or comorbidities. Attach progress notes, BMI calculations, and diet/exercise plans signed by your provider.
Electronic PA through ePA platforms speeds things up, with decisions in 24-72 hours. Fax submissions go to 1-888-487-9257, with follow-up via phone at 1-866-814-5506.
Follow Up on Review
Expect a response within 3 business days for non-urgent requests. If more info is needed, provide it promptly to avoid denial. Track status on the CVS Caremark portal using your member ID.
Denials often cite incomplete docs or unmet criteria—appeal within 180 days with added evidence.
Key Documentation for Approval
Gathering the right paperwork upfront smooths the path. Height and weight measurements for BMI are essential, along with a signed statement on diet and exercise commitment.
Comorbidity details, like A1C for diabetes or lipid panels, add weight to your request. Photos or journals of prior weight loss efforts can illustrate failures with non-drug approaches.
Pharmacy claims history proves step therapy compliance. Your doctor’s rationale letter ties it all together, explaining why Wegovy is the best fit.
Comparing Wegovy Coverage Across PBMs
While criteria vary, CVS Caremark’s process shares similarities with others. Here’s a table outlining key differences for popular managers.
| PBM | Preferred Status for Wegovy | Key Criteria | Typical Approval Timeline |
|---|---|---|---|
| CVS Caremark | Preferred (Tier 2 since 2025) | BMI ≥30 or ≥27 w/comorbidities; 3-mo step therapy | 3 business days |
| Express Scripts | Non-preferred in some plans | Similar BMI; prior generic trials required | 5-7 business days |
| OptumRx | Preferred for obesity | Comorbidities emphasized; renewal w/5% loss | 2-4 business days |
This overview highlights CVS Caremark’s efficiency for Wegovy seekers. Check your plan’s specifics for nuances.
Navigating Denials and Appeals
Denials happen, often due to missing BMI proof or step therapy gaps. Review the explanation of benefits for reasons, then gather overlooked docs.
Appeals start with your doctor resubmitting via the same channels. Include peer-reviewed studies on Wegovy’s efficacy for your condition to bolster the case.
External reviews through state insurance departments offer another layer if internal appeals fail. Persistence pays off—over 50% of appeals succeed with solid evidence.
Tips for Providers and Patients
Team up early—discuss PA during your first Wegovy consult. Patients, track weights and habits in an app for easy sharing.
Providers, use templates for notes to meet criteria consistently. Electronic tools like CoverMyMeds integrate with EHRs for faster ePA.
Stay updated on formulary changes; Wegovy’s 2025 preferred shift eases access but monitor annual reviews.
Recent Changes in 2025 Formulary
As of July 1, 2025, CVS Caremark named Wegovy the sole preferred GLP-1 for weight loss, dropping competitors like Zepbound from standard lists. Existing PAs transitioned automatically, extending coverage dates.
This move aims to cut costs while prioritizing proven options. Members with OSA or heart risks benefit from streamlined approvals tied to weight loss goals.
Novo Nordisk supports access via copay cards, capping out-of-pocket at $225 for eligible patients during PA waits.
Lifestyle Integration with Wegovy
Approval isn’t the end—pair Wegovy with habits for best results. Aim for 150 minutes of weekly exercise, like walking, to amplify effects.
Balanced meals with veggies and proteins sustain energy. Track progress monthly to prep for renewals, showing that 4-5% loss at three months.
Support groups or apps foster accountability, turning PA efforts into long-term success.
Cost Considerations Post-Approval
With PA secured, copays vary by tier—often $25-50 for preferred drugs. Manufacturer savings reduce it further for commercials.
Medicare plans exclude weight loss coverage, routing through diabetes indications if applicable. Explore patient assistance for uninsured gaps.
Annual deductibles influence totals; budget accordingly post-approval.
When to Reapply or Switch
Renew PAs 30 days before expiration, updating with recent weights. If goals stall, discuss dose tweaks or adjunct therapies.
Switching PBMs during open enrollment? Compare formularies—Wegovy’s broad acceptance helps. Consult HR for plan details.
Summary
Securing Wegovy through CVS Caremark involves clear criteria focused on medical need and prior efforts. From BMI verification to step therapy docs, preparation ensures smoother approvals in this preferred 2025 formulary era. Patients and providers partnering early see higher success rates, unlocking Wegovy’s benefits affordably.
Remember, PA is a gateway to sustained health gains. Track progress, appeal denials promptly, and integrate lifestyle changes for optimal outcomes. With these steps, coverage becomes a stepping stone to wellness.
FAQ
What BMI qualifies for Wegovy under CVS Caremark?
A BMI of 30 or higher, or 27 or higher with comorbidities like diabetes or hypertension. Documentation from recent measurements is required in the PA submission. This aligns with FDA guidelines for chronic weight management.
How long does CVS Caremark take to review Wegovy PA?
Most non-urgent requests get a decision in 3 business days. Electronic submissions via ePA can be faster, often 24-72 hours. Follow up if additional info is requested to speed things up.
What if my Wegovy PA is denied?
Review the denial reason, like missing step therapy proof, and appeal within 180 days. Resubmit with enhanced docs, including doctor rationale and studies. Over half of appeals succeed with complete evidence.
Does Wegovy require step therapy with CVS Caremark?
Yes, typically a 3-month trial of a lower-cost option like an oral appetite suppressant. Exceptions apply for intolerances or cardiovascular risks. Pharmacy records confirm compliance.
How do I renew my Wegovy prior authorization?
Submit 30 days before expiration, showing at least 5% weight loss after initial months. Include updated BMI, labs, and continued lifestyle notes. Approvals often extend 6-12 months.