Cigna appeal guide
Cigna Wegovy coverage appeal
Cigna uses specific clinical-policy criteria for Wegovy. Most denials come from undocumented BMI history or missing step-therapy notes. Here is how to address both.
Cigna prior authorization criteria for Wegovy
- BMI ≥30 (or ≥27 + comorbidity)
- Lifestyle intervention documented ≥3 months
- Specific comorbidity ICD-10 codes required (E66.x, I10, E11.x most common)
Step-by-step appeal flow
- 1
Pull your carrier policy bulletin
Cigna publishes its Wegovy coverage criteria. Read it first — every successful appeal cites it back to the reviewer.
- 2
Document your medical necessity
BMI ≥30 (or ≥27 + comorbidity) Lifestyle intervention documented ≥3 months Specific comorbidity ICD-10 codes required (E66.x, I10, E11.x most common)
- 3
Have your prescriber submit the PA
Most Cigna PAs go through CoverMyMeds or the carrier portal. Your prescriber attaches BMI history, comorbidities (with ICD-10 codes), lifestyle program participation, and prior weight-loss attempts.
- 4
If denied — file the appeal within 60 days
Cite Cigna Coverage Position Criteria PH-1518. Include ICD-10 codes verbatim in the letter.
- 5
Submit external review if internal appeals fail
After two internal appeals, you can request external review through your state insurance commissioner. ERISA plans go through the federal external-review process.
Letter template
Customizable Cigna appeal letter
We provide a generic medical-necessity letter generator. Customize with the Cigna-specific framing above for highest first-pass success.
Generate appeal letterCommon questions readers ask
- How much does Wegovy cost without insurance?
- List price runs ~$1,350/mo at retail. NovoCare Pharmacy cash-pay direct from Novo Nordisk is $499/mo for all dose strengths. The Wegovy Savings Offer caps copay at $0-$225/mo for commercially insured patients depending on coverage status (not a flat $225 for everyone). Full evidence-graded answer
- Is Ozempic the same as Wegovy?
- Same active molecule (semaglutide), different FDA indications and maximum doses. Ozempic = type 2 diabetes, max 2 mg/week. Wegovy = chronic weight management, max 2.4 mg/week. Insurance pathways are very different. Full evidence-graded answer
- Can I still get compounded GLP-1 in 2026?
- For semaglutide: no — FDA declared the shortage resolved February 21, 2025 and 503A compounding is no longer broadly permitted. For tirzepatide: shortage resolved October 2024 (re-affirmed December 2024), with a wind-down enforcement window that ended in 2025. Some clinics still market "compounded" formulations with added ingredients (B12, glycine) as personalized prescriptions; the legal status is contested. Full evidence-graded answer
- How does Wegovy compare to Saxenda?
- Both are GLP-1 agonists from Novo Nordisk. Wegovy (semaglutide, weekly) produces ~15% mean weight loss; Saxenda (liraglutide, daily) produces ~6-8%. Wegovy is also cheaper per kg-lost, more convenient, and has cardiovascular outcome data (SELECT trial). Saxenda was first approved for adolescents (2020); Wegovy followed in 2022 — both are available for ages 12-17. Full evidence-graded answer
Editorial information based on published Cigna coverage policies as of 2026. Your specific plan benefits may differ — confirm with your insurance card’s member services number. Not legal advice.