Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 27 or higher
- Established cardiovascular disease (MI, stroke, PAD, and coronary_revascularization)
- On guideline-directed medical therapy (lipid-lowering agent, antiplatelet, beta_blocker, and renin-angiotensin inhibitor)
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction - Established CVD without T2DM
All of:
- Patient is an adult (18 years or older)
- Request is NOT for Wegovy HD 7.2 mg injection
- Used with a reduced-calorie diet AND increased physical activity
- Patient does NOT have type 2 diabetes (patients with T2DM should use Ozempic for CV risk reduction)
- Baseline BMI >= 27 kg/m2 (obesity or overweight; if transitioning, use BMI at start of any drug therapy)
- Patient is currently receiving GDMT for cardiovascular disease OR has a clinical reason not to be treated with GDMT
Plus any one of:
- Previous MI
- Previous stroke
- Symptomatic PAD evidenced by intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
- Prior history of revascularization (CABG, PCI, or angioplasty)
Documentation to bring
- Documentation of qualifying CVD event (previous MI, previous stroke, symptomatic PAD with ABI < 0.85 or revascularization or amputation, or prior CABG/PCI/angioplasty)
- Baseline BMI documentation (>= 27 kg/m2; if transitioning, BMI at start of any drug therapy)
- Documentation of current GDMT use (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor) OR clinical reason GDMT is not appropriate
- Confirmation that patient does NOT have type 2 diabetes
Quantity limits
- 0.25mg/0.5mL, 0.5mg/0.5mL, 1mg/0.5mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.7mg/0.75mL, 2.4mg/0.75mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.5mg tablet, 4mg tablet, 9mg tablet, 25mg tablet — 30 tablets / 25 days; 90 tablets / 75 days (84-day)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for At continuation, patient must still have established CV disease with a qualifying event history AND be on a maintenance dose based on individual treatment response and tolerability. Used with reduced-calorie diet and increased physical activity. Note: T2DM exclusion and GDMT requirement are NOT re-verified at continuation per the policy's continuation criteria (continuation criteria only re-check CV event history and maintenance dose, not GDMT or T2DM exclusion).
Not covered when
- Wegovy HD 7.2 mg injection is excluded for this indication
- Type 2 diabetes patients are directed to Ozempic for CV risk reduction instead
- Concomitant use with other semaglutide-containing products is not recommended
- Concomitant use with any other GLP-1 receptor agonist is not recommended
Policy note: Both Wegovy injection and Wegovy tablets are covered for CV risk reduction in adults, but Wegovy HD 7.2 mg injection is explicitly excluded for this indication. The policy notes that Ozempic is indicated for CV risk reduction in adults with T2DM and established CVD; Wegovy CV risk reduction explicitly excludes patients with T2DM. GDMT examples listed: lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor. DOA is 12 months for both initial and continuation.
verified June 2, 2026 · source: 4774-C_Wegovy.pdf