Does Empire Plan Cover Wegovy for Weight Loss? Criteria and Costs

Yes, the Empire Plan does cover Wegovy for weight loss. The drug sits on the 2026 Advanced Flexible Formulary under “Anti-Obesity Agents,” but every prescription requires prior authorization, and your prescriber has to document that you meet specific clinical criteria before CVS Caremark will approve the fill.¹

Formulary Status and the Prior Authorization Requirement

Wegovy carries a “PA” designation on the 2026 formulary managed by CVS Caremark, the Empire Plan’s pharmacy benefit manager. Every anti-obesity medication on the list carries the same flag, including Zepbound, Contrave, and generic liraglutide.¹

Being on the formulary is not the same as being covered for you. The plan’s materials state the formulary “is not all-inclusive and does not guarantee coverage,” and that enrollees pay the full cost of any medication an approved exception does not cover.¹ The prior authorization is where coverage is actually decided.

Clinical Criteria You Have to Meet

CVS Caremark publishes the clinical policy it uses for Wegovy prior authorization decisions. The Empire Plan may apply its own version, but the published policy is the clearest guide to what your prescriber will need to show.²

For adults, approval generally requires:

Age 18 or older.
A baseline BMI of 30 or higher, or 27 or higher with at least one weight-related condition such as hypertension, type 2 diabetes, or high cholesterol.
Participation in a comprehensive weight management program with behavioral modification, dietary changes, and physical activity for at least six months before starting drug therapy.
Use of the medication alongside a reduced-calorie diet and increased physical activity.

Patients aged 12 to 17 follow a parallel pathway, with a baseline BMI at or above the 95th percentile for age and sex and the same six-month program requirement.³

Initial approval for the injection runs roughly seven to eight months. To continue past that, adults must show at least a 5% loss from baseline body weight, or maintenance of that 5% loss after at least three months at a stable dose. Continuation approvals extend coverage to 12 months.²

What You Will Pay

Wegovy is a brand-name drug, so once approved it falls under either Level 2 (preferred brand) or Level 3 (non-preferred brand). The formulary does not spell out which level applies, so you’ll need to verify through CVS Caremark. The 2026 copays are:⁴

Level 1 generic: $5 for 30 days; $10 for 90 days at retail.
Level 2 preferred brand: $30 for 30 days; $60 for 90 days at retail.
Level 3 non-preferred brand: $60 for 30 days; $120 for 90 days at retail.

Mail order matches retail for a 30-day supply. On a 90-day supply, mail order runs slightly less: $55 at Level 2 and $110 at Level 3, versus $60 and $120 at retail.⁴ To confirm your tier and copay, log in at empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447), option 4.

Can State Employees Use the Wegovy Savings Card?

Yes, in most cases. Novo Nordisk’s savings card can bring copays down to as little as $25 per month, with a maximum savings of $100 per one-month fill. The company’s eligibility terms state that “insurance provided through state employee plans” is not treated as a federal or state government health care program for purposes of this offer, so Empire Plan enrollees are not categorically excluded the way Medicare or Medicaid beneficiaries are.⁵

Two cautions. The card cannot be used if your plan runs an alternate funding program that requires you to apply for manufacturer assistance as a condition of coverage, and its value can be clawed back if the plan uses accumulator adjustment or copay maximizer programs. Check with CVS Caremark on these before counting the savings into your budget.⁵

If Your Prior Authorization Is Denied

Denials are common with anti-obesity medications, and documentation is usually the deciding factor on appeal. A strong appeal file includes:

Current BMI and weight records that meet the plan’s thresholds.
Documentation of a weight management program with start date, duration, and the components involved (dietary counseling, physical activity, behavioral support).
A history of prior treatments: medications tried, start and stop dates, and why each was discontinued or failed.
Relevant comorbidities such as type 2 diabetes, hypertension, sleep apnea, or cardiovascular disease, with supporting labs or diagnostics.
A letter of medical necessity from your provider tying the medication to specific health risks rather than weight alone.

Novo Nordisk offers a sample appeal letter through its NovoCare program, and providers can call NovoCare Support at 1-888-809-3942 for help assembling the appeal.⁶ Industry data cited by one weight-care provider puts the overturn rate for internal appeals of weight-loss medication denials at roughly 44%.⁷

If Wegovy Isn’t the Right Fit

The 2026 formulary lists three other anti-obesity agents, each with its own prior authorization: Zepbound (tirzepatide), Contrave (naltrexone/bupropion), and liraglutide, the generic form of Saxenda.¹

One boundary worth knowing. Ozempic and Mounjaro appear on the formulary under “Incretin Mimetic Agents” for type 2 diabetes, not weight loss. Off-label use for weight management would not typically meet their standard authorization criteria, so if weight loss is the goal, Wegovy or Zepbound is the covered pathway, not Ozempic.¹ The plan separately excludes weight loss programs themselves, though a drug prescribed independently by a physician still follows the formulary pathway described above.⁸

1
NYS Department of Civil Service. Empire Plan Advanced Flexible Formulary Preferred Drug List
2
CVS Caremark. Clinical Criteria for Wegovy (Semaglutide)
3
CVS Caremark. Wegovy Prior Authorization Form
4
NYS Department of Civil Service. Empire Plan Benefit Comparison
5
Novo Nordisk. Wegovy Savings Card Eligibility
6
Novo Nordisk. Wegovy Sample Letter of Appeal
7
Knownwell. How to Get Insurance to Cover Weight Loss Medication
8
NYS Department of Civil Service. Choices 2026 Active