Applies to Employer plans.
Depends on your plan's benefitExpanded indications must NOT be restricted from coverage under the patient's pharmacy benefit.
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction — Initial Approval
All of:
- Expanded indications are NOT restricted from coverage under the patient's pharmacy benefit
- Requested agent is FDA labeled for the requested indication and route of administration (Wegovy)
- Patient has a BMI ≥ 27 kg/m2
- Patient does NOT have type 2 diabetes
- Patient's age is 45 years or over
- Patient is currently being treated in the past 90 days with antihypertensive therapy (ACE inhibitor, ARB, or beta blocker)
- Patient is currently being treated in the past 90 days with lipid lowering therapy (any statin or ezetimibe)
- Patient will continue antihypertensive therapy AND lipid lowering therapy in combination with the requested agent
- Prescriber is a specialist (e.g., cardiologist) or has consulted with a specialist
- Patient will NOT use the requested agent in combination with another weight loss agent
- Patient is currently on and will continue weight management regimen (low-calorie diet, increased physical activity, behavioral modifications)
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications
- Patient has tried and failed at least three formulary alternatives OR prescriber indicates alternatives are contraindicated, likely less effective, or likely to cause adverse reaction
Plus any one of:
- History of myocardial infarction
- History of stroke
- Peripheral artery disease defined by intermittent claudication with ankle-brachial index < 0.85 at rest, or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
Tobacco Use Requirement
Plus any one of:
- Patient does NOT currently use any tobacco products (cigarettes, chewing tobacco)
- Patient is being managed for tobacco cessation
Documentation to bring
- Medical records documenting established cardiovascular disease (CAD, ACS, history of MI, angina, revascularization, PCI/CABG, stroke, TIA, carotid or arterial stenosis, PAD including aortic aneurysm, all of atherosclerotic origin)
- Medical records confirming qualifying CV event: MI, stroke, or PAD (intermittent claudication with ABI < 0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
- Documentation of BMI ≥ 27 kg/m2
- Documentation that patient does NOT have type 2 diabetes
- Documentation that patient is age 45 or over
- Documentation of current antihypertensive therapy (ACE inhibitor, ARB, or beta blocker) within past 90 days
- Documentation of current lipid-lowering therapy (statin or ezetimibe) within past 90 days
- Documentation of tobacco use status or active tobacco cessation management
- Documentation of specialist involvement (cardiologist) or consultation
- Documentation of formulary alternatives tried and failed (at least 3), or clinical reason alternatives are contraindicated/less effective/harmful
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: At renewal: patient must have clinical benefit with the requested agent. CV qualifying event and T2DM exclusion are re-verified at renewal. GDMT requirement at renewal is slightly relaxed: patient must be treated with antihypertensive therapy AND/OR lipid-lowering therapy (initial approval requires BOTH antihypertensive AND lipid-lowering therapy). Tobacco cessation requirement is re-verified. Specialist requirement is re-verified.
Not covered when
- Type 2 diabetes (explicitly excluded — this indication requires absence of T2DM)
- Co-administration with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Co-administration with another GLP-1 receptor agonist
- Any FDA labeled contraindications
Policy note: Established CVD is broadly defined in this policy to include: CAD, ACS, history of MI, stable or unstable angina, coronary or other arterial revascularization, prior PCI/CABG, stroke, TIA, carotid or other arterial stenosis, or PAD including aortic aneurysm (all of atherosclerotic origin). However, for the qualifying CV event (criteria #3), only MI, stroke, or PAD (as specifically defined) qualify. At renewal, GDMT requirement is slightly relaxed from 'both antihypertensive AND lipid-lowering' to 'antihypertensive AND/OR lipid-lowering.' Managed by Prime Therapeutics.
Policy effective April 1, 2026 · verified June 5, 2026 · source: BCBS Minnesota Employer / Commercial Insurance prior authorization policy · View policy document (PDF)