Wegovy prior authorization: what to submit
A Wegovy request is three different requests depending on why it is written. Weight is the use plans most often exclude; heart-risk reduction and MASH are uses a plan judges on their own criteria, and each needs its own diagnosis on file.
What does a Wegovy prior authorization need?
For heart-risk reduction: established cardiovascular disease — a prior heart attack, stroke or peripheral arterial disease — with obesity or overweight, dated in the chart. For weight: a BMI in the label's populations with the baseline, and the lifestyle attestation. For MASH: fibrosis staged F2 to F3, without cirrhosis. In every case, no history of medullary thyroid carcinoma or MEN 2, and no second GLP-1. At renewal, 6 of the 7 covering state programs on this site that publish a renewal rule ask for 5% of starting weight lost.
The 3 uses, and what each needs
Cardiovascular risk reduction
Who the label covers: Adults with established cardiovascular disease and either obesity or overweight.
- The cardiovascular diagnosis with its date: a prior heart attack, stroke or peripheral arterial disease. SELECT, the trial behind this use, enrolled people 45 or older with a BMI of 27 or more and no diabetes.
- The request filed as cardiovascular risk reduction. It is a different use from weight, and a plan that excludes weight loss judges it on its own terms.
Weight management
Who the label covers: Adults with obesity, or with overweight and a weight-related condition; adolescents from 12 with obesity.
- A current and a baseline BMI. For an adolescent, a BMI at or above the 95th percentile for age and sex, which is how the state criteria on this site that cover adolescents define it.
- The weight-related condition named and dated where the BMI is under the obesity line.
MASH
Who the label covers: Adults with noncirrhotic MASH and moderate to advanced liver fibrosis, stages F2 to F3, under accelerated approval.
- The fibrosis stage and how it was established, and cirrhosis ruled out — the approval excludes it.
- The request written as MASH, not as weight.
Indications read from FDA prescribing information for WEGOVY, via DailyMed.
What every request carries
- No personal or family history of medullary thyroid carcinoma or MEN 2. It is the boxed warning, and every published GLP-1 criteria set asks; a blank answer is read as a fail.
- No second GLP-1 alongside it. Every state document on this site that addresses it says so, and a pharmacy claims history is how they check.
- Diet and physical activity as part of treatment. The label pairs every use with them, and criteria ask for it in writing.
- The indication written on the request in the label's words. A form that reads 'weight loss' invites a weight-loss exclusion even when the diagnosis behind it is something else.
What renewal asks
A first approval is the easy half. Renewal is where a weight-management request is tested on the result, and the test is written down: these are the state programs on this site that cover a GLP-1 for weight and whose document sets a renewal rule. Commercial plans publish theirs in the criteria documents linked from each insurer's page.
| Program | First approval | What renewal needs |
|---|---|---|
| Delaware | 6 months | At least 5% of baseline weight for adults and 4% for adolescents, then another 6 months in 90-day supplies. Regaining more than half of what was lost, or falling back under those thresholds at any point, can block renewal for a year. |
| Michigan | 6 months | Approvals granted before 1 January 2026 ran out their six months by 30 June 2026; the new criteria have applied at every renewal since |
| Minnesota | 6 months | 5% weight loss for adults, or a 5% reduction in baseline BMI at 12–17, and past 18 months the loss has to be maintained |
| Mississippi | 6 months | A loss of 5% or more of body weight buys another 6 months. A loss of 1 to 4% can buy 3 months, but only where titration was delayed by intolerance, hospitalization or illness, or another non-scale goal was met. Under 1% is a denial. Once at goal or under a BMI of 25 the request moves to maintenance, also 6 months, which asks that weight stay within 15% of the goal BMI. Adherence means three claims in the past 105 days. |
| North Carolina | 6 months | 5% body weight loss for adults, 4% BMI reduction for adolescents, and it has to hold |
| Tennessee | 12 months | Renewal requires chart notes documenting a loss of at least 5% of baseline body weight — of baseline BMI-for-age under 18 — and continued participation in the lifestyle program. Someone who misses that can be approved for one more month to titrate off. |
| Virginia | 6 months | 6 more months on 5% weight loss; renewals stop once BMI falls under 25 |
How long the plan has
Set by regulation for each plan type, not by the plan. Which one you are on decides the clock.
Employer and marketplace plans
A standard prior authorization has to be decided within 15 days of the request, extendable once by 15; an urgent one within 72 hours. You have at least 180 days from a denial to appeal inside the plan, then four months from the final denial to ask for independent external review, unless the plan is grandfathered. 29 CFR 2560.503-1; 45 CFR 147.136
Medicare Part D, on its own or inside Medicare Advantage
72 hours for a standard coverage determination and 24 for an expedited one; for an exception the clock starts when the prescriber's supporting statement arrives. 60 days from the notice to ask the plan for a redetermination, longer if you show good cause. 42 CFR 423.568; 42 CFR 423.572; 42 CFR 423.582
Medicaid, fee-for-service or managed care
Federal Medicaid law requires an answer to a drug prior authorization within 24 hours, and a 72-hour emergency supply while it is pending. In a managed care plan you have 60 days from a denial to appeal to the plan, which must decide within 30 days, or 72 hours if it is urgent. On a decision the state makes itself, it may allow up to 90 days to ask for a fair hearing. Social Security Act §1927(d)(5); 42 CFR 438.402; 42 CFR 438.408; 42 CFR 431.221
Where your plan's own criteria are
Wegovy prior authorization, answered
- What are the prior authorization criteria for Wegovy?
- It depends on which of its three uses the request is for. Heart-risk reduction needs established cardiovascular disease with obesity or overweight; weight needs a BMI in the label's populations and usually a lifestyle program; MASH needs fibrosis at stages F2 to F3 without cirrhosis. Your plan adds the thresholds and the renewal test.
- Can Wegovy be approved for heart disease if my plan excludes weight loss?
- Yes, if you have established cardiovascular disease: that use is not weight loss, and an exclusion written against weight loss does not reach it. The request has to be filed as cardiovascular risk reduction with the diagnosis on record.
- Do adolescents need different criteria for Wegovy?
- The label covers adolescents from 12 with obesity. State criteria on this site define that as a BMI at or above the 95th percentile for age and sex, and their renewal tests for adolescents are sometimes written as a share of BMI rather than of weight.