Applies to Employer plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
CV risk reduction - MACE prevention
All of:
- Patient is 45 years of age or older
- BMI > 27 kg/m2
- Established cardiovascular disease (prior MI, prior stroke, or symptomatic PAD)
- Receiving Standard of Care (SOC) treatment appropriate for their CV condition
- Patient is NOT NYHA class IV heart failure
Plus any one of:
- Prior MI
- Prior stroke
- Symptomatic PAD with current intermittent claudication and ABI < 0.85 at rest
- Prior peripheral arterial revascularization procedure
- Prior amputation due to ASCVD
Documentation to bring
- Documentation that patient is 45 years of age or older
- Documentation of BMI > 27 kg/m2
- Documentation of qualifying established cardiovascular disease event: prior MI, prior stroke, or symptomatic PAD (with ABI < 0.85, prior peripheral arterial revascularization, or prior amputation due to ASCVD)
- Documentation of current Standard of Care (SOC) treatment including examples from: antiplatelet agents (aspirin or P2Y12 inhibitor), lipid-lowering drugs (statin, ezetimibe, fibrate, or PCSK9 inhibitor), antihypertensives (beta blocker, ACE-I, ARB)
- Documentation confirming patient is NOT NYHA class IV heart failure
- For continuation: claims records demonstrating > 80% fill rate
- For continuation: documentation that patient has not developed Type 2 Diabetes or NYHA class IV heart failure
- For continuation: documentation of ongoing SOC therapies for CVD
- For continuation: documentation of FDA approved maintenance dose (injection 1.7 or 2.4 mg, or oral tablet 25 mg)
Quantity limits
- all strengths — 1-month supply (28 to 30 days); 75% of days must be exhausted before refill
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: Individual must continue to meet initial approval criteria AND remain adherent (>80% fill rate per claims records) AND not have developed Type 2 Diabetes or NYHA class IV heart failure AND remain on Standard of Care therapies for CVD AND be on FDA approved maintenance dose (Wegovy injection 1.7 or 2.4 mg; Wegovy oral tablet 25 mg). Note: initial CV criteria (age ≥ 45, established CVD, BMI > 27, SOC treatment) are re-verified at continuation per policy language.
- Renewal: Staying on a maintenance dose of at least 1.7 mg.
Not covered when
- NYHA class IV heart failure
- Wegovy HD is NOT FDA approved for CV risk reduction (MACE)
- Mail order pharmacy benefit excluded
- Members with BCBSMA Focused Formulary: not a covered benefit effective 1/1/2026
- Development of Type 2 Diabetes during treatment is a disqualifier for continuation
- Requests based exclusively on use of samples will not meet coverage criteria
Policy note: Policy requires SOC treatment; prescriber must provide examples of all applicable SOC medications. Symptomatic PAD must be evidenced by ABI < 0.85 at rest, prior peripheral arterial revascularization procedure, or prior amputation due to ASCVD. Wegovy HD is explicitly excluded from the CV risk reduction indication. Oral Wegovy is included for CV risk reduction per 1/8/2026 update. Continuation requires patient has NOT developed T2D (development of T2D disqualifies continuation for this indication).
Policy effective May 1, 2026 · verified June 2, 2026 · source: 572%20 GLP-1%20and%20 GLP-1%20 %20 Gip%20 Agonist%20 Drugs%20for%20 Anti Obesity%20 Management%20and%20 Other%20 Non Obesity%20 Conditions · View policy document (PDF)