Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 45 and older
- BMI of 27 or higher
- A1C no higher than 6.4%
- Established cardiovascular disease (prior_MI, prior_stroke_ischemic, prior_stroke_hemorrhagic, TIA, angina_pectoris_with_atherosclerosis_>=50%_stenosis, prior_PTCA, prior_CABG, symptomatic_carotid_stenosis_>=50%, prior_carotid_endarterectomy, carotid_artery_angioplasty_and_stenting, aortic_aneurysm_secondary_to_atherosclerosis, history_of_aortic_aneurysm_repair, symptomatic_PAD_with_intermittent_claudication_ABI<0.85, peripheral_arterial_revascularization, and amputation_due_to_atherosclerotic_disease)
- On guideline-directed medical therapy (antiplatelet_agent (aspirin or P2Y12 inhibitor), lipid-lowering drug (statin, ezetimibe, fibrate, or PCSK9 inhibitor), and antihypertensive therapy (beta blocker, ACE-I, or ARB))
- Lab results confirming eligibility
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
Initial Authorization - CV Risk Reduction (Wegovy injection or tablet)
All of:
- Patient is 45 years of age or older (ages 18-44 denied as not medically necessary; age <18 denied as investigational)
- BMI >= 27 kg/m2 (BMI 25 to <27 denied as not medically necessary; BMI <25 denied as investigational)
- Patient does NOT have Type I or Type II Diabetes Mellitus diagnosis AND does not have HbA1c >= 6.5%
- Patient does NOT have NYHA Class IV heart failure, chronic pancreatitis, or acute pancreatitis within the last 180 days
- Patient does NOT have personal history of, or first-degree relative with, medullary thyroid carcinoma or personal history of MEN 2
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient will NOT use medication in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- Patient will use medication in combination with guideline-directed pharmacotherapy for CVD (antiplatelet agent, lipid-lowering drug, and antihypertensive therapy)
Plus any one of:
- Prior myocardial infarction (MI)
- Prior stroke (ischemic or hemorrhagic) or documented history of TIA
- Angina pectoris with significant atherosclerosis (>= 50% stenosis)
- Prior PTCA or CABG
- Symptomatic carotid stenosis (>= 50% stenosis)
- Prior carotid endarterectomy or carotid artery angioplasty and stenting
- Aortic aneurysm secondary to atherosclerosis or history of aortic aneurysm repair
- Symptomatic PAD evidenced by: intermittent claudication with ABI <0.85 (at rest), OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease
Continuation Authorization - CV Risk Reduction (Wegovy injection)
All of:
- Patient has received an initial authorization for Wegovy injection or tablets
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient had a BMI >= 27 kg/m2 prior to initiation of therapy (BMI 25 to <27 at initiation denied as not medically necessary; BMI <25 at initiation denied as investigational)
- Patient has NOT developed Type II DM since the previous authorization
- Patient does NOT have NYHA Class IV heart failure, chronic pancreatitis, or acute pancreatitis within the last 180 days
- Patient will continue guideline-directed pharmacotherapy for CVD (antiplatelet agent, lipid-lowering drug, and antihypertensive therapy)
- Patient is tolerating a Wegovy injection maintenance dose of 2.4 mg once weekly
- Patient will NOT use medication in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
Plus any one of:
- Prior MI
- Prior stroke (ischemic or hemorrhagic) or documented history of TIA
- Angina pectoris with significant atherosclerosis (>= 50% stenosis)
- Prior PTCA or CABG
- Symptomatic carotid stenosis (>= 50% stenosis)
- Prior carotid endarterectomy or carotid artery angioplasty and stenting
- Aortic aneurysm secondary to atherosclerosis or history of aortic aneurysm repair
- Symptomatic PAD evidenced by: intermittent claudication with ABI <0.85 (at rest), OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease
Continuation Authorization - CV Risk Reduction (Wegovy tablet)
All of:
- Patient has received an initial authorization for Wegovy injection or tablets
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient had a BMI >= 27 kg/m2 prior to initiation of therapy (BMI 25 to <27 at initiation denied as not medically necessary; BMI <25 at initiation denied as investigational)
- Patient has NOT developed Type II DM since the previous authorization
- Patient does NOT have NYHA Class IV heart failure, chronic pancreatitis, or acute pancreatitis within the last 180 days
- Patient will continue guideline-directed pharmacotherapy for CVD (antiplatelet agent, lipid-lowering drug, and antihypertensive therapy)
- Patient is tolerating a Wegovy tablet maintenance dose of 25 mg once daily
- Patient will NOT use medication in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
Plus any one of:
- Prior MI
- Prior stroke (ischemic or hemorrhagic) or documented history of TIA
- Angina pectoris with significant atherosclerosis (>= 50% stenosis)
- Prior PTCA or CABG
- Symptomatic carotid stenosis (>= 50% stenosis)
- Prior carotid endarterectomy or carotid artery angioplasty and stenting
- Aortic aneurysm secondary to atherosclerosis or history of aortic aneurysm repair
- Symptomatic PAD evidenced by: intermittent claudication with ABI <0.85 (at rest), OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease
Documentation to bring
- Documentation of patient age >= 45 years
- Baseline BMI documentation >= 27 kg/m2
- Documentation of established CVD qualifying event (prior MI, prior stroke/TIA, angina with >= 50% stenosis, prior PTCA/CABG, symptomatic carotid stenosis >= 50%, prior carotid endarterectomy/stenting, aortic aneurysm, or symptomatic PAD with ABI <0.85/revascularization/amputation)
- Documentation confirming no diagnosis of Type I or Type II Diabetes Mellitus
- HbA1c lab result confirming HbA1c < 6.5%
- Documentation of current guideline-directed pharmacotherapy for CVD (antiplatelet agent, lipid-lowering drug, and antihypertensive therapy) or clinical justification if any component is not used
- Documentation confirming no NYHA Class IV heart failure diagnosis
- Documentation confirming no chronic pancreatitis and no acute pancreatitis within the last 180 days
- Documentation confirming no personal history or first-degree family history of medullary thyroid carcinoma or MEN 2
- Prescriber attestation that medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Prescriber attestation that medication will NOT be used in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- For continuation (injection): Documentation that patient is tolerating Wegovy injection maintenance dose of 2.4 mg once weekly
- For continuation (tablet): Documentation that patient is tolerating Wegovy tablet maintenance dose of 25 mg once daily
- For continuation: Documentation confirming patient has not developed Type II DM since previous authorization
Approval and renewal
- Initial approval: 6 months
- To renew, the plan looks for For continuation: patient must have established CVD (same qualifying events as initial), must have had a baseline BMI >= 27 kg/m2 prior to therapy initiation, must not have developed Type II DM since previous authorization, must not have NYHA Class IV heart failure/chronic pancreatitis/acute pancreatitis within last 180 days, must continue GDMT, and must be tolerating maintenance dose (2.4 mg/week for injection or 25 mg/day for tablet). Age >= 45 is NOT re-verified at continuation. A1C exclusion (>=6.5%) is NOT explicitly re-verified at continuation (only new T2DM diagnosis is checked) and staying on a maintenance dose of at least 2.4 mg.
Not covered when
- Type II Diabetes Mellitus diagnosis
- HbA1c >= 6.5%
- NYHA Class IV heart failure
- Chronic pancreatitis
- Acute pancreatitis within the last 180 days
- Personal history of medullary thyroid carcinoma
- First-degree relative with medullary thyroid carcinoma
- Personal history of Multiple Endocrine Neoplasia type 2 (MEN 2)
- Concomitant use with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- Age < 18 (investigational)
- Age 18-44 (denied as not medically necessary)
- BMI < 25 (investigational)
- BMI 25 to <27 (denied as not medically necessary)
- Use without concomitant behavioral modification and reduced-calorie diet (investigational)
- No established cardiovascular disease (not covered for contracts excluding obesity medications; not medically necessary for contracts including obesity medications)
- Type 1 diabetes
Policy note: Policy covers both Wegovy injection and Wegovy tablet for CV risk reduction. Initial authorization is for 6 months. For contracts that INCLUDE obesity medication coverage, the established CVD requirement and GDMT requirement are additional company requirements (denial as not medically necessary if not met). For contracts that EXCLUDE obesity medication coverage, lack of established CVD results in a not covered determination. Wegovy tablet lacks a dedicated CV outcomes trial; support for this indication is based on pharmacokinetic modeling. The policy explicitly excludes patients with T1DM or T2DM AND HbA1c >= 6.5% (considered investigational). Ages 18-44 are denied as not medically necessary (not investigational). Minimum maintenance dose for continuation of injection is 2.4 mg/week; for tablet is 25 mg/day.
Policy effective May 1, 2026 · verified June 2, 2026 · source: 00886%2020240812%20Wegovy%20semaglutideaccessible%20pdf.pdf