Employer / Commercial Insurance
Depends on your plan's benefitFor members WITH the anti-obesity benefit, this is covered under that benefit. For Delaware Commercial fully-insured or Healthcare Reform members WITHOUT the anti-obesity benefit, coverage is available under Section V criteria. This section explicitly applies to 'members with a DE Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit only'.
What you need to qualify
- Age 18 and older
- BMI of 27 or higher
- Diagnosis documented with a code (I21, I63, I73.9)
- 6 months of a documented diet and exercise program
- Established cardiovascular disease (MI, stroke, and PAD)
- On guideline-directed medical therapy (statin, ezetimibe, and PCSK9_inhibitor)
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction Initiation (Section V) — Delaware without anti-obesity benefit
All of:
- Member is 18 years of age or older
- Drug is being used for major adverse cardiovascular event risk reduction
- Baseline height, weight, and BMI documented within 6 months prior to initiating requested medication and/or a GLP-1 medication
- Baseline BMI >= 27 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
- Member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
- Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
- 0 to < 7 months of previous therapy
Plus any one of:
- Member has pre-existing diagnosis of myocardial infarction (ICD-10: I21)
- Member has pre-existing diagnosis of stroke (ICD-10: I63)
- Member has pre-existing diagnosis of peripheral arterial disease (ICD-10: I73.9) with documentation of: intermittent claudication with ABI < 0.85 at rest, OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease
CV Risk Reduction — GDMT: Statin + Ezetimibe pathway
All of:
- Member will use Wegovy as adjunct to maximally-tolerated statin therapy
- Member will use Wegovy as adjunct to ezetimibe
CV Risk Reduction — GDMT: Statin-intolerant pathway
All of:
- Member has experienced therapeutic failure, contraindication, or intolerance to ezetimibe monotherapy
Plus any one of:
- While receiving at least two separate trials of different statins, member experienced statin-related rhabdomyolysis (resolved upon discontinuation) OR skeletal-related muscle symptoms (resolved upon discontinuation)
- Member experienced CK increase to 10x ULN during any course of statin therapy
- Member experienced LFTs increase to 3x ULN during any course of statin therapy
- Member was hospitalized due to severe statin-related adverse event (e.g., rhabdomyolysis)
CV Risk Reduction — GDMT: PCSK9 inhibitor pathway
Plus any one of:
- Member will use Wegovy as adjunct to a PCSK9 inhibitor (e.g., Praluent, Repatha)
- Member has experienced therapeutic failure, contraindication, or intolerance to a PCSK9 inhibitor (e.g., Praluent, Repatha)
CV Risk Reduction — T2DM step therapy (if applicable)
All of:
- If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes AND FDA-approved for cardiovascular risk reduction (e.g., Ozempic)
Documentation to bring
- Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must show BMI >= 27 kg/m2)
- Documentation of pre-existing qualifying CVD event: myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with supporting documentation of ABI < 0.85 at rest, revascularization procedure, or amputation due to atherosclerotic disease
- Documentation of current use of maximally-tolerated statin therapy AND ezetimibe, OR documentation of statin intolerance (at least two separate statin trials with rhabdomyolysis/muscle symptoms resolving upon discontinuation; OR CK > 10x ULN, LFTs > 3x ULN, or hospitalization due to severe statin-related AE) AND therapeutic failure/contraindication/intolerance to ezetimibe monotherapy
- Documentation of current use of a PCSK9 inhibitor (e.g., Praluent, Repatha) as adjunct, OR documentation of therapeutic failure, contraindication, or intolerance to PCSK9 inhibitor
- Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
- Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
- If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA that is FDA-approved for both diabetes and CV risk reduction (e.g., Ozempic)
- Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
- For maintenance: documentation that requested dose is 1.7 mg or 2.4 mg once weekly (injection) or 25 mg once daily (oral tablet), or prescriber attestation of titrating to maintenance dose
Approval and renewal
- Initial approval: 7 months
- Renewal: every 12 months
- To renew, the plan looks for At maintenance/continuation, the CV qualifying event (MI, stroke, or PAD), BMI >= 27, GDMT requirements (statin/ezetimibe and PCSK9 inhibitor), and T2DM step therapy are all re-verified. No weight loss threshold is required for continuation. Maintenance dose requirements: Wegovy injection 1.7 mg or 2.4 mg once weekly (or titrating to this); Wegovy oral tablet 25 mg once daily (or titrating to this). Note: 7.2 mg (Wegovy HD) is NOT a recommended maintenance dose for CV risk reduction and staying on a maintenance dose of at least 1.7 mg.
Not covered when
- Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
- If T2DM diagnosed: must have failed a preferred diabetes GLP-1 RA with CV indication (e.g., Ozempic) before Wegovy is approved for CV risk reduction
- 7.2 mg dose (Wegovy HD) is NOT a recommended maintenance dose for cardiovascular risk reduction
- Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
- Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
- Pancreatitis occurring while on therapy — do not switch to another agent
- Pregnancy
Exceptions
- Delaware: Section V (CV risk reduction) applies ONLY to Delaware Commercial fully-insured or Healthcare Reform plan members WITHOUT the anti-obesity benefit. Members with the anti-obesity benefit would access Wegovy for CV risk reduction under standard benefit criteria.
Policy note: This section applies specifically to Delaware members without the anti-obesity benefit. The GDMT requirement is layered: member must meet BOTH the statin/ezetimibe pathway (or statin intolerance exception) AND the PCSK9 inhibitor pathway (use or prior failure). If member has T2DM, they must have failed a GLP-1 RA approved for both diabetes and CV risk reduction (example given: Ozempic) before Wegovy is approved. The CV risk reduction indication does not exclude T2DM patients but requires prior GLP-1 failure in T2DM patients. This is distinct from the weight_loss indication which explicitly excludes T2DM patients. Initiation = up to 7 months; maintenance = up to 12 months.
Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf