Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV Risk Reduction - Initial Approval
All of:
- Requested use is to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke) in adults with established CVD
- Patient is either obese or overweight
- Requested agent is FDA labeled for the requested indication and route of administration
- Patient does NOT have type 2 diabetes
- Patient BMI ≥ 27 kg/m^2
- Patient age ≥ 45 years
- Currently being treated in the past 90 days with antihypertensive therapy (e.g., ACE inhibitor, ARB, beta blocker)
- Currently being treated in the past 90 days with lipid lowering therapy (e.g., any statin, 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
Plus any one of:
- History of myocardial infarction
- History of stroke
- Peripheral artery disease as defined by intermittent claudication with ankle-brachial index < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
CV Risk Reduction - Tobacco Use
Plus any one of:
- Patient does NOT currently use any tobacco products (e.g., cigarettes, chewing tobacco)
- Patient is being managed for tobacco cessation
Documentation to bring
- Medical records confirming history of qualifying CV event (MI, stroke, or PAD as defined)
- Documentation of BMI ≥ 27 kg/m^2
- Documentation that patient does NOT have type 2 diabetes
- Documentation of patient age ≥ 45 years
- Documentation of current antihypertensive therapy within past 90 days (ACE inhibitor, ARB, or beta blocker)
- Documentation of current lipid-lowering therapy within past 90 days (any statin or ezetimibe)
- Documentation of tobacco non-use or enrollment in tobacco cessation management
- Documentation of specialist prescriber or specialist consultation (e.g., cardiologist)
Quantity limits
- 0.25 MG/0.5 ML injection, 0.5 MG/0.5 ML injection, 1 MG/0.5 ML injection — 8 Pens per 180 days (84-day)
- 1.7 MG/0.75 ML injection, 2.4 MG/0.75 ML injection — 4 Pens per 28 days
- 7.2 MG/0.75 ML injection (Wegovy hd) — 4 Pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient must demonstrate clinical benefit with the requested agent. At renewal, GDMT requirement is softened: antihypertensive and/or lipid-lowering therapy (vs. both required at initial). BMI, T2DM exclusion, and age ≥ 45 requirements are not re-verified at renewal. Tobacco use/cessation requirement remains. Specialist/specialist consultation remains required.
Not covered when
- Type 2 diabetes explicitly excluded from CV risk reduction pathway
- Current tobacco use (unless managed for cessation)
- Any FDA labeled contraindications to the requested agent
Policy note: PAD qualification requires intermittent claudication with ankle-brachial index < 0.85 at rest, OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease. At renewal, the GDMT requirement changes from requiring BOTH antihypertensive AND lipid-lowering therapy to antihypertensive therapy AND/OR lipid-lowering therapy. Initial approval requires both; renewal requires at least one. Specialist (e.g., cardiologist) or specialist consultation required at both initial and renewal.
Policy effective June 1, 2026 · verified June 4, 2026 · source: Wy Weight Management Paql Prog Sum · View policy document (PDF)