Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV Risk Reduction — Initial Approval
All of:
- Patient is an adult
- Drug is being used with a reduced calorie diet and increased physical activity
- Request is NOT for continuation of therapy
- Patient has established cardiovascular disease with history of at least ONE qualifying CV event
- Baseline BMI ≥ 27 kg/m2
- Patient does NOT have type 2 diabetes
- Patient is currently receiving GDMT for cardiovascular disease OR has clinical reason not to be treated with GDMT (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor)
Plus any one of:
- Previous myocardial infarction (MI)
- Previous stroke
- Symptomatic peripheral arterial disease (PAD) evidenced by intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
- Prior history of revascularization (CABG, PCI, or angioplasty)
CV Risk Reduction — Continuation of Therapy
All of:
- Request is for continuation of therapy
- Patient has established cardiovascular disease with history of at least ONE qualifying CV event
- Patient is being treated with a maintenance dosage of the requested drug
Plus any one of:
- Previous myocardial infarction (MI)
- Previous stroke
- Symptomatic peripheral arterial disease (PAD) evidenced by intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
- Prior history of revascularization (CABG, PCI, or angioplasty)
Documentation to bring
- Documentation of qualifying cardiovascular disease event (previous MI, previous stroke, symptomatic PAD with ABI < 0.85 or revascularization or amputation, or prior CABG/PCI/angioplasty)
- Baseline BMI documentation (≥ 27 kg/m2)
- Documentation confirming patient does NOT have type 2 diabetes (initial approval only)
- Documentation of current GDMT use (e.g., lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor) OR clinical reason GDMT is not appropriate (initial approval only)
- For continuation: documentation that patient is being treated with a maintenance dosage of the requested drug
Quantity limits
- 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens) / 63 days (84-day)
- 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens) / 63 days (84-day)
Approval and renewal
- Initial approval: 7 months
- Renewal: every 12 months
- Renewal: Continuation requires: (1) established cardiovascular disease with history of qualifying CV event AND (2) patient is being treated with a maintenance dosage of the requested drug. T2DM exclusion, BMI requirement, and GDMT requirement are NOT re-verified at continuation.
Not covered when
- Type 2 diabetes — patients with T2DM should use Ozempic for CV risk reduction per policy note
- Coadministration with other semaglutide-containing products is not recommended
- Coadministration with any other GLP-1 receptor agonist is not recommended
Policy note: Policy explicitly states that patients with type 2 diabetes should use Ozempic (not Wegovy) for CV risk reduction: 'Ozempic is indicated to reduce the risk of major cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease. Patients with type 2 diabetes may be treated for risk reduction of cardiovascular events with Ozempic.' PAD qualifying criterion requires ABI < 0.85 at rest, or peripheral arterial revascularization, or amputation due to atherosclerotic disease. GDMT examples listed: lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor. Policy number 4774-C, version UDR 08-2023 v2.
verified June 5, 2026 · source: 14017 156760120 · View policy document (PDF)