Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV risk reduction - initial approval (Wegovy injection only, not HD)
All of:
- Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection
- Used with reduced-calorie diet AND increased physical activity
- Patient does NOT have type 2 diabetes
- Baseline BMI ≥ 27 kg/m2
- Currently receiving GDMT for CVD OR has clinical reason not to receive GDMT
Plus any one of:
- Previous MI
- Previous stroke
- Symptomatic PAD with ABI < 0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease
- Prior history of revascularization (CABG, PCI, or angioplasty)
Documentation to bring
- Documentation of qualifying CVD event (MI, stroke, PAD with ABI < 0.85/revascularization/amputation, or prior CABG/PCI/angioplasty)
- Baseline BMI documentation (≥ 27 kg/m2)
- Documentation of current GDMT use (lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor) OR clinical reason GDMT is not appropriate
- Documentation confirming patient does NOT have type 2 diabetes
Quantity limits
- 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Continuation requires: established CVD history (one of MI, stroke, PAD, revascularization) re-verified; patient being treated with maintenance dosage based on individual treatment response and tolerability. T2DM exclusion and GDMT requirement are NOT re-verified at continuation per the continuation criteria section.
Not covered when
- Type 2 diabetes patients are excluded (directed to Ozempic instead)
- Wegovy HD 7.2 mg injection is excluded from CV risk reduction coverage
- Wegovy tablets have a separate CV risk reduction DOA of 12 months but criteria are not separately detailed in the document
Policy note: Policy explicitly states patients with T2DM may be treated for CV risk reduction with Ozempic instead. Wegovy tablets are also approved for CV risk reduction per FDA and listed in DOA section (12 months) but the detailed criteria section specifies 'Wegovy ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)' without separately calling out tablets — tablets appear to fall under same CV criteria. GDMT examples listed: lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor.
Policy effective April 10, 2026 · verified June 2, 2026 · source: Policy 260