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Centene · Heart Disease Risk Reduction

Centene coverage for Wegovy (Heart Disease Risk Reduction)

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • 6 months of a documented diet and exercise program
  • Prior trial of 3 other GLP-1 medications (Ozempic, Rybelsus, Trulicity, and liraglutide (generic Victoza)) for at least 90 days
  • Established cardiovascular disease (MI, stroke, and PAD)
  • On guideline-directed medical therapy (statin, ezetimibe, fibrate, omega-3 fatty acids, PCSK9 inhibitor, ACE_inhibitor, ARB, calcium channel blocker, thiazide diuretic, beta_blocker, antiplatelet therapy, and antithrombotic therapy)

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction — No Concurrent T2DM

All of:

  • Established CVD: history of MI, history of stroke, or symptomatic PAD (ABI < 0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
  • Age >= 18 years
  • BMI >= 27 kg/m2
  • Prescriber attestation of current cardiovascular standard of care management
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Documentation of baseline body weight in kg
  • Dose within approved escalation schedule (up to 2.4 mg/week injection or 25 mg/day tablet)

CV Risk Reduction — With Concurrent T2DM

All of:

  • Established CVD: history of MI, history of stroke, or symptomatic PAD
  • Age >= 18 years
  • BMI >= 27 kg/m2
  • Prescriber attestation of current cardiovascular standard of care management
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Documentation of baseline body weight in kg
  • Dose within approved escalation schedule
  • Trial of >= 3 consecutive months each of ALL of: Ozempic or Rybelsus, Trulicity, and liraglutide (generic Victoza), unless clinically significant adverse effects or all are contraindicated (Note: IL HIM requests exempt from step therapy as of 1/1/2026 per IL HB 5395)
  • If currently on a GLP-1 and switching to Wegovy: medical justification supports necessity (intolerance due to common GI adverse effects is NOT acceptable justification)

Documentation to bring

  • Office chart notes, lab results, or other clinical information supporting all approval criteria
  • Documentation of qualifying CVD event (history of MI, history of stroke, or symptomatic PAD with ABI < 0.85 / revascularization / amputation)
  • BMI documentation >= 27 kg/m2
  • Prescriber attestation that member is currently receiving cardiovascular standard of care management
  • Documentation of active enrollment in physician-directed weight loss program for at least 6 months
  • Documentation of member's baseline body weight in kg
  • For concurrent T2DM: documentation of >= 3-month trial each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) (unless adverse effects or all contraindicated), except IL HIM as of 1/1/2026
  • If switching from another GLP-1: medical justification supporting necessity for Wegovy specifically

Quantity limits

  • 0.25mg, 0.5mg, 1mg
  • 1.7mg, 2.4mg
  • 1.5mg tablet, 4mg tablet, 9mg tablet, 25mg tablet — 1 tablet per day

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, First renewal: must have lost >= 5% of baseline body weight. Second and subsequent renewals: must have lost weight and/or maintained weight loss. Maintenance dose >= 1.7 mg/week (injection) or 25 mg/day (tablet) required. GDMT requirement and lifestyle program enrollment re-verified at continuation. Prior GLP-1 step therapy NOT re-checked at continuation, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Concomitant use with other semaglutide-containing products
  • Concomitant use with any other GLP-1 receptor agonist
  • Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 (contraindication)
  • Known hypersensitivity to semaglutide or excipients

Exceptions

  • Illinois: Step therapy requirements for members with concurrent T2DM do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: Symptomatic PAD defined per SELECT trial as intermittent claudication with ABI < 0.85 at rest, or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. Cardiovascular standard of care is broadly defined in Appendix D and includes condition-specific medications for dyslipidemia, hypertension, MI, stroke, and PAD. Wegovy tablets are approved only for CV event prevention indication (not MASH). Wegovy HD 7.2 mg injection formulation also available. IL HB 5395 exempts IL HIM requests from GLP-1 step therapy requirement for concurrent T2DM as of 1/1/2026.

Policy effective June 1, 2024 · verified June 2, 2026 · source: CP.PMN.295.pdf

All Wegovy policies under Centene · Check your card