Does NYSHIP Cover Wegovy? Eligibility, Costs, and Denials

Yes, NYSHIP covers Wegovy. The drug appears on the Empire Plan’s Advanced Flexible Formulary under “Anti-Obesity Agents,” but the plan pays nothing until CVS Caremark approves a prior authorization request submitted by the prescribing provider.¹² Once approved, Wegovy sits at the highest copayment tier: $60 for a 30-day retail supply and $110 through mail order for a 90-day supply in 2026.³

Who Qualifies for Wegovy Under the Empire Plan

CVS Caremark administers the prior authorization review. For adults using Wegovy for weight loss, the criteria require either a BMI of 30 or higher, or a BMI of 27 or higher paired with a qualifying weight-related condition. Recognized comorbidities include hypertension, type 2 diabetes, dyslipidemia, coronary artery disease, osteoarthritis, and obstructive sleep apnea.⁴

In every adult weight-loss case, the patient must also have participated in a comprehensive weight management program — behavioral counseling, a reduced-calorie diet, and increased physical activity — for at least six months before starting the drug. Adolescents ages 12 to 17 can qualify with a baseline BMI at or above the 95th percentile for their age and sex, and the same six-month lifestyle requirement applies.⁴

Two other indications open separate paths to approval. Adults with established cardiovascular disease (prior heart attack, stroke, peripheral artery disease, or revascularization), a BMI of at least 27, and no type 2 diabetes diagnosis can qualify to reduce the risk of major cardiovascular events. Adults with moderate-to-advanced noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) can qualify when Wegovy is prescribed by or in consultation with a gastroenterologist or hepatologist.⁴

The prescriber submits the request, but preparation on the patient side helps. The paperwork needs to document BMI, any qualifying comorbidities, participation in the weight management program, and, for the cardiovascular or MASH indications, the relevant clinical history.⁴

Staying Covered After the First Approval

Initial approval doesn’t lock in coverage indefinitely. To keep filling the prescription, adults must show a loss of at least five percent of baseline body weight — or maintenance of that loss — after at least three months on a stable maintenance dose. For adolescents, the plan looks for a reduction from baseline BMI or maintenance of that reduction.⁴ If those markers aren’t met, continued coverage can be denied even after months of successful use.

What You Will Pay

Wegovy is classified as a non-preferred brand drug, which puts it at Level 3, the highest copay tier on the Empire Plan.¹ The 2026 copayments are:³

Retail, 30-day supply: $60
Retail, 90-day supply: $120
Mail order, 30-day supply: $60
Mail order, 90-day supply: $110

These copays assume PA has been approved. Without approval, the plan pays nothing and the member owes the full retail price.

Novo Nordisk Savings Card

The Wegovy savings card from manufacturer Novo Nordisk can bring the out-of-pocket cost down further. The program states that state employee health plans are not treated as government programs for eligibility, so NYSHIP enrollees are generally eligible.⁵ Eligible patients with commercial coverage can pay as little as $25 per month, with the program covering up to $100 per one-month supply. Patients whose insurance uses copay accumulator or maximizer programs, or an alternate funding program that requires manufacturer savings as a condition of coverage, are not eligible. Members who later move to a government-funded plan must stop using the card.⁶

Where to Fill the Prescription

Wegovy is not on the Empire Plan’s Specialty Pharmacy Drug List, so it isn’t subject to the mandatory CVS Specialty dispensing rule that applies to many specialty medications.⁷ Members can fill it at any Empire Plan network retail pharmacy or through the mail-order program. To confirm current dispensing requirements, log in at empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447), option 4.⁸

Ozempic Is Not a Substitute for Wegovy Approval

Wegovy and Ozempic share an active ingredient, semaglutide, but the Empire Plan treats them as separate drugs. Ozempic is listed under “Incretin Mimetic Agents” in the antidiabetics section; Wegovy sits under “Anti-Obesity Agents.” Both require prior authorization, and each has its own clinical criteria tied to its FDA-approved use.¹ A weight-management prescription runs through the Wegovy pathway with the BMI and lifestyle requirements above, regardless of whether the patient also has diabetes.

If Your Prior Authorization Is Denied

A denial can be challenged through a multi-level appeal process.

Level 1 appeal: File within 180 days of the denial. The member or prescriber contacts CVS Caremark at CVS/caremark Prescription Claim Appeals, MC109, P.O. Box 52084, Phoenix, AZ 85072-2084, or by calling 1-877-7-NYSHIP, option 4. A reviewer not involved in the original decision handles the case.⁹
Level 2 appeal: If Level 1 upholds the denial, request a second-level review in writing or by phone within 60 days of receiving the Level 1 determination.
External appeal: For denials based on medical necessity, file with the New York State Department of Financial Services within four months of the final adverse determination. The DFS application line is 1-800-400-8882.⁹

Legislation That Could Change the Rules

New York lawmakers have introduced bills that would broaden insurance coverage of obesity treatments. Senate Bill S3104, sponsored by Senator Jeremy Cooney, would require insurance plans — including comprehensive state-sponsored plans like NYSHIP — to cover FDA-approved anti-obesity medications with terms no more restrictive than the drugs’ approved labeling, and would also cover nutrition counseling, behavioral therapy, and bariatric surgery.¹⁰ A companion bill, A04211, sits in the Assembly Insurance Committee. A separate measure, Senate Bill S5798, targets Medicaid managed care coverage of weight management drugs.¹¹

Neither bill has advanced past committee referral as of mid-2026. S3104 was referred to the Senate Health Committee in January 2025 and again in January 2026 with no hearings scheduled.¹² Until something passes, the prior authorization requirements above are what governs Wegovy access under the Empire Plan.

1
NYS Department of Civil Service. Empire Plan Advanced Flexible Formulary Drug List
2
NYS Department of Civil Service. Empire Plan Prescription Drug Program Prior Authorization List
3
NYS Department of Civil Service. Empire Plan Comparison
4
CVS Caremark. Wegovy Prior Authorization Criteria
5
NovoCare. Wegovy Savings Offer
6
NovoCare. Wegovy Savings Card Eligibility
7
NYS Department of Civil Service. Empire Plan Specialty Pharmacy Drug List
8
NYS Department of Civil Service. Reporting on the Empire Plan Prescription Drug Program
9
NYS Department of Civil Service. Empire Plan Report
10
LegiScan. New York Senate Bill S3104
11
New York State Senate. Senate Bill S5798
12
New York State Senate. Senate Bill S3104