HCSC coverage for Wegovy (Heart Disease Risk

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
Established cardiovascular disease (MI, stroke, and PAD)
On guideline-directed medical therapy (optimized pharmacotherapy for established cardiovascular disease)

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults with established CVD and obesity/overweight

All of:

Requested use is to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight
Requested agent is Wegovy
Patient has a pretreatment BMI >= 27 kg/m2
Patient will use optimized pharmacotherapy for established cardiovascular disease in combination with Wegovy
Patient does NOT have any FDA labeled contraindications

Plus any one of:

History of myocardial infarction
History of stroke
Peripheral artery disease as defined by intermittent claudication with ankle-brachial index < 0.85 at rest, or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

Documentation to bring

Documentation of established cardiovascular disease (CAD, ACS, history of MI, angina, revascularization, PCI/CABG, stroke, TIA, carotid or arterial stenosis, PAD including aortic aneurysm, all of atherosclerotic origin)
Documentation of qualifying CV event: MI, stroke, or PAD (with ABI < 0.85, revascularization, or amputation due to atherosclerotic disease)
Baseline BMI documentation (>= 27 kg/m2)
Documentation of current or planned optimized pharmacotherapy for established cardiovascular disease

Quantity limits

0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML — 8 pens per 180-day supply (84-day)
1.7 MG/0.75ML, 2.4 MG/0.75ML — 4 pens per 28-day supply
7.2 MG/0.75ML — 4 pens per 28-day supply
1.5 MG tablet, 4 MG tablet, 9 MG tablet — 60 tablets per 180-day supply (84-day)
25 MG tablet — 30 tablets per 30-day supply

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for At renewal, patient must have had clinical benefit with Wegovy AND will continue optimized pharmacotherapy for established cardiovascular disease. Initial qualifying CV event documentation and BMI threshold are not explicitly re-verified at renewal.

Not covered when

Any FDA labeled contraindications to the requested agent

Exceptions

BCBS_NM_Fully_Insured_or_HIM: May be approved if patient does not have FDA labeled contraindications AND the requested indication is a rare disease AND patient has another FDA labeled indication or compendia-supported indication.
Ohio_Fully_Insured_or_HIM_SHOP: May be approved if member resides in Ohio, plan is Fully Insured or HIM Shop (SG), no FDA labeled contraindications, AND patient has another FDA labeled or compendia-supported indication OR prescriber submits two articles from major peer-reviewed journals.

Policy note: Established CVD is defined broadly as: CAD, ACS, history of MI, stable or unstable angina, coronary or other arterial revascularization, prior PCI/CABG, stroke, TIA, carotid or other arterial stenosis, or PAD including aortic aneurysm, all of atherosclerotic origin. The PAD qualifying criterion specifically requires: intermittent claudication with ABI < 0.85 at rest, OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease. GDMT specified as 'optimized pharmacotherapy for established cardiovascular disease' without naming specific drug classes.

Policy effective May 18, 2026 · verified June 2, 2026 · source: HCSC_Weight_Management_ProgSum.pdf

HCSC coverage for Wegovy (Heart Disease Risk Reduction)