Yes, NYSHIP’s Empire Plan covers Wegovy, but every prescription requires prior authorization through CVS Caremark before the plan will pay anything. Wegovy sits on the Empire Plan’s Advanced Flexible Formulary under “Anti-Obesity Agents” as a non-preferred brand drug, which puts it at the highest copayment tier.1NYS Department of Civil Service. Empire Plan Advanced Flexible Formulary Drug List Without an approved prior authorization, the plan pays no benefit at all and you are responsible for the full retail price.2NYS Department of Civil Service. Empire Plan Prescription Drug Program Prior Authorization List
What Prior Authorization Requires
Your prescriber submits the request, not you. CVS Caremark reviews it against clinical criteria. For adults seeking Wegovy for weight loss, one of the following must be documented:
- A BMI of 30 or higher, with no additional condition required, or
- A BMI of 27 or higher together with a qualifying comorbidity such as hypertension, type 2 diabetes, dyslipidemia, coronary artery disease, osteoarthritis, or obstructive sleep apnea.
In either case, the patient must 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 medication.3CVS Caremark. Wegovy Prior Authorization Criteria
Adolescents ages 12 to 17 can qualify with a baseline BMI at or above the 95th percentile for their age and sex, along with the same six-month lifestyle program.3CVS Caremark. Wegovy Prior Authorization Criteria
Two other paths to approval exist beyond weight loss alone. 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 for Wegovy to reduce the risk of major cardiovascular events. Adults with moderate-to-advanced noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) can qualify when a gastroenterologist or hepatologist prescribes or consults on the therapy.3CVS Caremark. Wegovy Prior Authorization Criteria
Before your doctor submits the request, make sure the chart has BMI, documentation of any qualifying comorbidities, proof of the six-month weight management program, and the relevant cardiovascular or liver history if those are the basis for coverage.
Keeping Coverage After the First Approval
Initial approval does not run indefinitely. To continue receiving Wegovy, adults must show at least five percent loss 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 in BMI from baseline or maintenance of that reduction.3CVS Caremark. Wegovy Prior Authorization Criteria
What You Will Pay
Once prior authorization is approved, Wegovy is dispensed at Level 3 copay rates. For 2026 those copays are:4NYS Department of Civil Service. Empire Plan Comparison
- Retail, 30-day supply: $60
- Retail, 90-day supply: $120
- Mail order, 30-day supply: $60
- Mail order, 90-day supply: $110
The Novo Nordisk Savings Card
Novo Nordisk’s Wegovy savings card can lower that cost further. The program states that state employee health plans are not considered government programs for the offer, so NYSHIP enrollees are generally eligible.5NovoCare. Wegovy Savings Offer Eligible commercial patients can pay as little as $25 per month, with the program covering up to $100 per one-month supply. Patients whose plan uses copay accumulator or maximizer programs, or an alternate funding program that requires manufacturer savings as a condition of coverage, are not eligible, and anyone who later moves to a government-funded plan must stop using the card.6NovoCare. Wegovy Savings Card Eligibility
Where You Can Fill It
Wegovy is not on the Empire Plan’s Specialty Pharmacy Drug List, so the mandatory CVS Specialty dispensing requirement does not apply.7NYS Department of Civil Service. Empire Plan Specialty Pharmacy Drug List You should be able to fill a prescription at any Empire Plan network retail pharmacy or through mail order. To confirm current dispensing rules, log in at empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447), option 4.8NYS Department of Civil Service. Reporting on the Empire Plan Prescription Drug Program
If Your Prior Authorization Is Denied
A denial can be appealed, and the Empire Plan uses a multi-level process for prescription drug decisions.9NYS Department of Civil Service. Empire Plan Report
- Level 1: File within 180 days of the denial. You or your doctor 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 qualified reviewer who was not involved in the original decision handles the case.
- Level 2: If Level 1 upholds the denial, request a second-level review in writing or by phone within 60 days of 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.
Legislation That Could Change These Rules
New York 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, along with nutrition counseling, behavioral therapy, and bariatric surgery.10LegiScan. New York Senate Bill S3104 A companion bill, A04211, sits in the Assembly Insurance Committee. Neither has advanced past its 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.11New York State Senate. Senate Bill S3104 Until something changes, the prior authorization requirements described above are what apply to your Wegovy prescription.