Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV risk reduction (Wegovy) — initial
All of:
- Requested use is to reduce risk of MACE (CV death, non-fatal MI, non-fatal stroke) in adults with established CVD and obesity or overweight
- Established CVD defined 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
- Requested agent is FDA labeled for the requested indication and route of administration (Wegovy)
- BMI ≥ 27 kg/m2
- Patient will use optimized pharmacotherapy for established CVD in combination with requested agent
- Patient is partaking in a heart healthy diet
- Patient is engaging in physical activity at their level of ability
- Patient will continue above lifestyle modifications while on therapy
- Documentation required
- Will NOT use in combination with another weight loss agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
- Currently on low-calorie diet, increased physical activity, and behavioral modifications
Plus any one of:
- History of myocardial infarction
- History of stroke
- History of peripheral artery disease (intermittent claudication with ankle-brachial index < 0.85 at rest, or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)
- Patient is currently a non-smoker (has not smoked in past 6 months)
- Patient is on a smoking cessation plan (documentation required)
Documentation to bring
- Documentation of established cardiovascular disease (CAD, ACS, MI, angina, revascularization, PCI/CABG, stroke, TIA, carotid/arterial stenosis, or PAD)
- Documentation of qualifying CVD event: history of MI, stroke, or PAD (with ABI < 0.85, revascularization, or amputation due to atherosclerotic disease)
- Documentation of BMI ≥ 27 kg/m2
- Documentation of current use of optimized pharmacotherapy for established CVD
- Documentation of non-smoker status (no smoking in past 6 months) OR smoking cessation plan
- Documentation of participation in heart healthy diet and physical activity
Quantity limits
- 0.25mg, 0.5mg, 1mg — 8 pens per 180 days (84-day)
- 1.7mg, 2.4mg — 4 pens per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- Renewal: Patient must have had clinical benefit with the requested agent. Continued use of optimized pharmacotherapy for established CVD required. T2DM exclusion and BMI/CVD event requirements are NOT re-verified at renewal — only clinical benefit and continued GDMT use are checked.
Not covered when
- Concomitant use with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Concomitant use with another GLP-1 receptor agonist
- Any FDA labeled contraindications to the requested agent
Policy note: Established CVD is broadly defined in this policy to include CAD, ACS, MI, stable/unstable angina, coronary/arterial revascularization, prior PCI/CABG, stroke, TIA, carotid/arterial stenosis, and PAD (including aortic aneurysm), all of atherosclerotic origin. Smoking cessation requirement: patient must be non-smoker (not smoked in past 6 months) OR on a smoking cessation plan. Initial approval 6 months. Renewal 6 months. No diabetes exclusion stated for this indication in the policy criteria (unlike weight loss pathway which explicitly excludes T2DM).
verified June 5, 2026 · source: GLP-1 For Non Diabetic Use · View policy document (PDF)