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Kaiser Permanente Mid-Atlantic

Does Kaiser Permanente Mid-Atlantic cover Wegovy for Heart Disease Risk Reduction?

Yes. Kaiser Permanente Mid-Atlantic covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 27 or higher. Other policy requirements and your plan's benefits also apply.

Policy document

  • Hmo Exchange Prior Authorization Criteria En

    Kaiser Permanente Mid-Atlantic · PA policy · Employer, ACA Marketplace, and Federal Employee Program

    Effective June 2, 2026. Verified June 5, 2026.

    View PDF Download Original insurer source
  • Employer, ACA Marketplace, and Federal Employee Program: Covered with requirements. See the qualification pathways below.

Earliest policy review June 5, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Heart Disease Risk Reduction (3 plan types)

Applies to Employer, ACA Marketplace, and Federal Employee Program plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

MACE risk reduction — established MI without diabetes

All of:

  • Age 55 to <75 years
  • Documented baseline weight within past 30 days
  • BMI ≥27 kg/m2
  • No history of diabetes (HbA1c <6.5%)
  • Established history of MI
  • Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
  • Optimized on ALL standard of care CVD treatments or documented intolerance/contraindication/rationale: (1) moderate- to high-intensity statin or alternative lipid-lowering medication, (2) antiplatelet medication, (3) antihypertensive medication
  • Not currently prescribed another GLP-1 RA- or GIP/GLP-1 RA-containing medication
  • Initial prescription limited to maximum 30-day supply with 2 refills
  • No reasons for non-coverage: not NYHA Class IV HF; no recent MI/stroke/hospitalization for unstable angina/TIA within 60 days; no planned coronary/carotid/peripheral artery revascularization; no T1D or T2D or HbA1c ≥6.5%; no history/presence of chronic or acute pancreatitis; no personal or first-degree relative history of MEN2 or MTC; not pregnant/breastfeeding/planning pregnancy/of childbearing potential without highly effective contraception; no ESRD/chronic or intermittent HD/PD; no malignant neoplasm within past 5 years (excluding basal/squamous cell skin cancer and carcinoma in-situ); no severe psychiatric disorder compromising adherence

Documentation to bring

  • Patient age documentation (55 to <75 years)
  • Documented baseline weight within past 30 days
  • BMI ≥27 kg/m2 documentation
  • HbA1c lab result confirming <6.5% (no history of diabetes)
  • Documentation of established history of MI
  • Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
  • Documentation of current use of moderate- to high-intensity statin or alternative lipid-lowering medication, OR documented intolerance/contraindication/rationale for not using
  • Documentation of current antiplatelet medication use, OR documented intolerance/contraindication/rationale
  • Documentation of current antihypertensive medication use, OR documented intolerance/contraindication/rationale
  • Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
  • Confirmation of absence of all reasons for non-coverage (NYHA Class IV HF, recent CV event within 60 days, planned revascularization, T1/T2DM, pancreatitis, MEN2/MTC history, pregnancy status, ESRD/dialysis, malignancy within 5 years, severe psychiatric disorder)
  • If ordering oral tablets: documented history of trypanophobia (fear of needles)

Quantity limits

  • all strengths — Maximum 30-day supply at initial prescription (with 2 refills); standard fill thereafter

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Must continue actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components). BMI must remain ≥27 kg/m2 (discontinue if BMI <27 kg/m2 as medication is no longer clinically indicated). Age, MI history, GDMT optimization, HbA1c exclusion, and other initial exclusions are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

  • Type 2 diabetes or HbA1c ≥6.5%
  • NYHA Class IV heart failure
  • Recent MI, stroke, hospitalization for unstable angina or TIA within 60 days prior to initiation
  • Planned coronary, carotid, or peripheral artery revascularization
  • History or presence of chronic or acute pancreatitis
  • Personal or first-degree relative history of MEN2 or MTC
  • Breastfeeding
  • Childbearing potential without highly effective contraception
  • ESRD, chronic or intermittent hemodialysis, or peritoneal dialysis
  • Malignant neoplasm within past 5 years (excluding basal/squamous cell skin cancer and carcinoma in-situ)
  • Severe psychiatric disorder compromising medication adherence
  • Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
  • Pregnancy
  • Type 1 diabetes

Policy note: Qualifying CV event is limited specifically to established history of MI (not broader CVD events like stroke, PAD, or revascularization). Age range is strictly 55 to <75. Diabetes exclusion defined as HbA1c <6.5% — excludes both T1D and T2D. Applies to Wegovy injectable and oral tablets; oral tablets require trypanophobia documentation. Initial prescription limited to 30-day supply with 2 refills. Continuation requires BMI ≥27 kg/m2; medication discontinued if BMI falls below 27.

Policy effective June 2, 2026 · verified June 5, 2026 · source: Hmo Exchange Prior Authorization Criteria En · View policy document (PDF)

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Questions people ask
Does Kaiser Permanente Mid-Atlantic cover Wegovy?
Yes. Kaiser Permanente Mid-Atlantic covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 27 or higher. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with Kaiser Permanente Mid-Atlantic?
Heart Disease Risk Reduction — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Initial approval: 6 months. Renewal: every 6 months.
What does Kaiser Permanente Mid-Atlantic require to renew Wegovy?
Heart Disease Risk Reduction — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Must continue actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components). BMI must remain ≥27 kg/m2 (discontinue if BMI <27 kg/m2 as medication is no longer clinically indicated). Age, MI history, GDMT optimization, HbA1c exclusion, and other initial exclusions are NOT explicitly re-verified for existing members who have previously met criteria.
How current is this information?
The oldest review date among the policies on this page is June 5, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Kaiser Permanente Mid-Atlantic: Mounjaro, Ozempic, Zepbound

Wegovy under other plans: Elevance Health, Maryland Medicaid, Virginia Medicaid, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid

All insurance plans · All medications

Summary of Kaiser Permanente Mid-Atlantic's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.