FEP Blue coverage for Wegovy (Heart Disease Risk Reduction)

What you need to qualify

• Age 18 and older
• BMI of 27 or higher
• 6 months of a documented diet and exercise program
• Established cardiovascular disease (congenital heart disease, cerebrovascular disease, PAD, coronary heart disease, ACS, MI, unstable angina, coronary or other arterial revascularization, prior PCI, and prior CABG)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of established cardiovascular disease (qualifying event or condition)
• Documentation of BMI >= 27 kg/m2
• Documentation of participation in a comprehensive weight management program
• Confirmation of no concurrent GLP-1 receptor agonist therapy
• Confirmation of no concurrent PA-required weight loss medication

Quantity limits

• all injection strengths — 12 single-dose pens per 84 days (84-day)
• tablet — 90 tablets per 90 days (84-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 and Patient must have lost at least 5% of baseline body weight OR maintained initial 5% weight loss. Comprehensive weight management program participation required. CV indication is covered under the weight management pathway with established CVD as a qualifying comorbidity (BMI >= 27 + established CVD). Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Dual therapy with another GLP-1 receptor agonist
• Dual therapy with another PA-required weight loss medication
• Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) [boxed warning contraindication]

Policy note: The policy does not have a standalone CV risk reduction section; this indication is covered under the weight management criteria with established CVD as a qualifying comorbidity for patients with BMI >= 27 kg/m2. The FDA-approved CV risk reduction indication (for adults with established CVD and obesity or overweight) is explicitly referenced in the regulatory status section for both injection and tablets. diabetes is not excluded for this pathway.

Policy effective February 13, 2026 · verified June 5, 2026 · source: FEP_Criteria_Wegovy.pdf