Fallon Health Plan coverage for Wegovy (Heart Disease Risk Reduction)

What you need to qualify

• Age 18 and older
• BMI of 35 or higher
• BMI of 30 or higher with a weight-related condition (established cardiovascular disease)
• Established cardiovascular disease (MI, stroke, and symptomatic PAD)

Qualification pathways

You can qualify through any one of these.

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
• To renew, the plan looks for at least 5% weight loss from the starting weight and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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: Pa policy