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Kaiser Permanente Mid-Atlantic · Heart Disease Risk Reduction

Kaiser Permanente Mid-Atlantic coverage for Wegovy (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 55 to 74
  • BMI of 27 or higher
  • A1C no higher than 6.4%
  • 3 months of a documented diet and exercise program
  • Established cardiovascular disease (MI)
  • On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

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
  • To renew, the plan looks for 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.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 55 to 74
  • BMI of 27 or higher
  • A1C no higher than 6.4%
  • 3 months of a documented diet and exercise program
  • Established cardiovascular disease (MI)
  • On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

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
  • To renew, the plan looks for 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.pdf

Federal Employee Program

Covered with requirements

What you need to qualify

  • Age 55 to 74
  • BMI of 27 or higher
  • A1C no higher than 6.4%
  • 3 months of a documented diet and exercise program
  • Established cardiovascular disease (MI)
  • On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

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
  • To renew, the plan looks for 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.pdf

All Wegovy policies under Kaiser Permanente Mid-Atlantic · Check your card