Elevance Health · Heart Disease Risk Reduction

Elevance Health coverage for Wegovy (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
A1C no higher than 6.5%
Established cardiovascular disease (MI, stroke, and PAD)
On guideline-directed medical therapy (antiplatelet_therapy, anticoagulant_therapy, high_intensity_statin, ACE_inhibitor, ARB, calcium_channel_blocker, thiazide_diuretic, and beta_blocker (required for history of MI))
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults without diabetes

All of:

Established cardiovascular disease (prior MI, prior stroke, or symptomatic PAD)
HbA1c < 6.5% (48 mmol/mol) — excludes Type 2 diabetes
BMI >= 27 kg/m2 documented within 90 days of request
Established on GDMT including antiplatelet/anticoagulant therapy, high-intensity statin, and blood pressure lowering therapy (unless not tolerated or not clinically warranted); beta blocker required for history of MI
Wegovy used as add-on to GDMT
Wegovy used in combination with healthy lifestyle counseling
Wegovy used in combination with reduced calorie diet and increased physical activity

Plus any one of:

Previous myocardial infarction
Previous stroke (ischemic or hemorrhagic)
Symptomatic peripheral arterial disease (intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)

Documentation to bring

Documentation of qualifying established CVD event: prior MI, prior stroke, or symptomatic PAD (with ABI <0.85, revascularization, or amputation)
HbA1c lab result < 6.5% (48 mmol/mol)
BMI documentation >= 27 kg/m2 within 90 days of request
Documentation of current GDMT use (antiplatelet/anticoagulant, high-intensity statin, blood pressure lowering therapy) or clinical reason not appropriate
Documentation of beta blocker use for individuals with history of MI, or clinical reason not appropriate
Confirmation that Wegovy will be used as add-on to GDMT
Confirmation that Wegovy will be used with healthy lifestyle counseling and reduced calorie diet and increased physical activity

Quantity limits

0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Continuation criteria not explicitly detailed in the document beyond initial approval duration of 1 year. No separate continuation criteria listed for CV risk reduction indication.

Not covered when

BMI < 18.5 kg/m2
Type 2 diabetes (HbA1c >= 6.5%)
Personal or family history of Medullary Thyroid Carcinoma (MTC)
Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Concurrent use of another semaglutide agent or any other GLP-1 agonist
History of suicide attempts or active suicidal ideation
Type 1 diabetes

Policy note: The CV risk reduction indication explicitly excludes both Type 1 and Type 2 diabetes (HbA1c must be < 6.5%). Symptomatic PAD is defined as intermittent claudication with ankle-brachial index <0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. GDMT requirement has exceptions for intolerance or lack of clinical warrant. Beta blocker is only required for individuals with history of MI. BMI documentation must be within 90 days of request. Approval duration is 1 year.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

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