Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 45 and older
- BMI of 27 or higher
- A1C no higher than 6.5%
- 6 months of a documented diet and exercise program
- Prescribed by or in consultation with a specialist
- Established cardiovascular disease (MI, stroke, and PAD)
- On guideline-directed medical therapy (statin, platelet_aggregation_inhibitor, ACE_inhibitor, ARB, beta_blocker, calcium_channel_blocker, and ARNI)
- Lab results confirming eligibility from the last 12 months
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
Initial Approval: Wegovy for CV Risk Reduction
All of:
- Age >= 45 years
- BMI >= 27 kg/m2
- Established cardiovascular disease (prior MI, prior ischemic or hemorrhagic stroke, or symptomatic PAD as defined below)
- HbA1c < 6.5% within past 12 months
- Does NOT have type 1 or type 2 diabetes (gestational diabetes excluded from this restriction)
- Does NOT have NYHA Class IV heart failure
- Where clinically appropriate, is on guideline-directed standard of care for CV condition (e.g., lipid-lowering therapy, platelet aggregation inhibitors, ACE inhibitors or ARBs, beta blockers, calcium channel blockers, ARNI)
- Will be used as adjunct to a program supporting reduced calorie diet (>= 500 kcal/day reduction) and >= 150 min/week activity
- Prescribed by or in consultation with a Cardiologist
- Failure, contraindication, or intolerance to THREE generic equivalents (if available) for at least 3 months each
- No personal or family history of medullary thyroid carcinoma or MEN2
- No prior serious hypersensitivity reaction to semaglutide
- No concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists
- No chronic pancreatitis or recent (within 180 days) acute pancreatitis
- No severe gastroparesis
- Not pregnant (if of childbearing potential)
Plus any one of:
- Prior myocardial infarction
- Prior ischemic or hemorrhagic stroke
- Symptomatic PAD: intermittent claudication with ABI < 0.85 at rest
- Symptomatic PAD: peripheral arterial revascularization procedure
- Symptomatic PAD: amputation due to atherosclerotic disease
Continuation/Renewal: Wegovy for CV Risk Reduction
All of:
- Continues to be seen by physician specializing in diagnosis or in consultation with a Cardiologist
- Confirmed established cardiovascular disease (same qualifying events as initial)
- HbA1c < 6.5% within past 12 months
- Does NOT have type 1 or type 2 diabetes
- Does NOT have NYHA Class IV heart failure
- Adherence to medication and guideline-directed standard of care for established CV condition
- Requested dose is at least 1.7 mg weekly
- Will be used as adjunct to reduced calorie diet (>= 500 kcal/day) and >= 150 min/week activity
- Failure, contraindication, or intolerance to THREE generic equivalents for at least 3 months each
- No personal or family history of medullary thyroid carcinoma or MEN2
- No prior serious hypersensitivity reaction to semaglutide
- No concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists
- No chronic pancreatitis or recent (within 180 days) acute pancreatitis
- No severe gastroparesis
- No sustained increase in resting heart rate
- Not pregnant (if of childbearing potential)
Plus any one of:
- Reduction of >= 5% in body weight from baseline
- Reduction of >= 3% body weight from baseline WITH decrease in LDL or triglycerides
- Reduction of >= 3% body weight from baseline WITH decrease in waist circumference
- Reduction of >= 3% body weight from baseline WITH decrease in blood pressure
Documentation to bring
- Completed prior authorization request form
- Chart notes documenting established cardiovascular disease (prior MI, prior stroke, or symptomatic PAD with qualifying criteria)
- HbA1c lab result within past 12 months (must be < 6.5%)
- Documentation of current body weight / BMI (>= 27 kg/m2)
- Documentation of current guideline-directed standard of care medications for CV condition, or clinical reason GDMT is not appropriate
- Documentation of failure, contraindication, or intolerance to three generic equivalents for at least 3 months each
- Prescriber attestation that patient does not have type 1 or type 2 diabetes
- Prescriber attestation that patient does not have NYHA Class IV heart failure
- For renewal: chart notes documenting >= 5% body weight reduction OR >= 3% reduction with qualifying secondary benefit
- For renewal: lab values confirming safe continued use
- For renewal: supporting clinical documentation of adherence
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, At renewal, patient must have achieved and maintained ONE of: (1) >= 5% reduction in body weight from baseline, OR (2) >= 3% body weight reduction from baseline WITH at least one of: decrease in LDL or triglycerides, decrease in waist circumference, or decrease in blood pressure. Also requires continued adherence to medication and guideline-directed standard of care for established CV condition. Minimum dose of 1.7 mg weekly required at renewal. HbA1c < 6.5% and absence of T1DM/T2DM are re-verified at continuation. GDMT requirement is re-verified at continuation (adherence required). Note: brand-specific criteria (3 generic equivalent failures) are also re-checked at renewal, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Type 2 diabetes (gestational diabetes is excluded from this restriction)
- NYHA Class IV heart failure
- Personal or family history of medullary thyroid carcinoma or MEN2
- Prior serious hypersensitivity reaction to semaglutide
- Concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists (e.g., Ozempic, Rybelsus, Trulicity, tirzepatide)
- Chronic pancreatitis or recent (within 180 days) acute pancreatitis
- Severe gastroparesis
- Sustained increase in resting heart rate (continuation only)
- Pregnancy
- Type 1 diabetes
Policy note: This PCG applies to Commercial and/or Marketplace plans. It does NOT apply to Federal Employee Program, Medicare Advantage, Medicaid, or out-of-state BCBS plans. Brand-specific criteria require failure, contraindication, or intolerance to THREE generic equivalents (if available) for at least 3 months each. Qualifying PAD includes: (1) intermittent claudication with ABI < 0.85 at rest, (2) peripheral arterial revascularization procedure, or (3) amputation due to atherosclerotic disease. GDMT examples listed include lipid-lowering therapy, platelet aggregation inhibitors, ACE inhibitors or ARBs, beta blockers, calcium channel blockers, and angiotensin receptor neprilysin inhibitor (ARNI). Manufacturer samples/assistance not accepted for continuation of therapy. Initial approval is 6 months or end of plan year; continuation is 12 months or end of plan year. HbA1c lookback period is 12 months.
Policy effective May 16, 2024 · verified June 2, 2026 · source: Download