How long does a Wegovy approval last with Fallon Health Plan?

Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.

What does Fallon Health Plan require to renew Wegovy?

Heart Disease Risk Reduction — Applies to Medicaid plans. At least one of: (1) weight loss ≥ 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation related to anti-obesity therapy despite lack of weight reduction AND AHI ≥ 15; (4) documentation of improvement in secondary measures with provider attestation related to anti-obesity therapy despite lack of weight reduction.

How current is this information?

The oldest review date among the policies on this page is May 25, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Fallon Health Plan

Does Fallon Health Plan cover Wegovy for Heart Disease Risk Reduction?

Yes. Fallon Health Plan covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 35 or higher, or 30 or higher with a related condition. Other policy requirements and your plan's benefits also apply.

Policy document

Fallon Health Plan Medicaid prior authorization policy

Fallon Health Plan · PA policy · Medicaid

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Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review May 25, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Heart Disease Risk Reduction (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults with established CVD and obesity

All of:

Established cardiovascular disease (history of MI, history of stroke, or symptomatic PAD)
Obesity or overweight (BMI criteria same as weight loss indication)

Documentation to bring

Documentation of established cardiovascular disease (history of MI, history of stroke, or symptomatic PAD)
Baseline BMI documentation
For continuation: documentation of established CVD and using GLP-1 for cardiovascular risk reduction, OR ≥ 5% weight loss, OR improvement in secondary measures with provider attestation

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
Renewal: At least one of: (1) weight loss ≥ 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation related to anti-obesity therapy despite lack of weight reduction AND AHI ≥ 15; (4) documentation of improvement in secondary measures with provider attestation related to anti-obesity therapy despite lack of weight reduction.

Policy note: CV risk reduction indication shares the same criteria framework as weight loss indication for Wegovy and Zepbound per the February 17, 2026 update. The continuation criteria explicitly allow continuation if member has established CVD and is using GLP-1 for cardiovascular risk reduction even without weight loss. Adults only (not pediatric) based on context.

source: Fallon Health Plan Medicaid prior authorization policy · View policy document (PDF)

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Questions people ask

Does Fallon Health Plan cover Wegovy?: Yes. Fallon Health Plan covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 35 or higher, or 30 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with Fallon Health Plan?: Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does Fallon Health Plan require to renew Wegovy?: Heart Disease Risk Reduction — Applies to Medicaid plans. At least one of: (1) weight loss ≥ 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation related to anti-obesity therapy despite lack of weight reduction AND AHI ≥ 15; (4) documentation of improvement in secondary measures with provider attestation related to anti-obesity therapy despite lack of weight reduction.
How current is this information?: The oldest review date among the policies on this page is May 25, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Fallon Health Plan: Ozempic

Wegovy under other plans: BCBS Massachusetts, Massachusetts Medicaid, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid

All insurance plans · All medications

Summary of Fallon Health Plan's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.