Kaiser Permanente Northern California coverage for

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
BMI of 25 or higher for patients of Asian descent
Established cardiovascular disease (prior_MI, prior_stroke_ischemic, prior_stroke_hemorrhagic, carotid_artery_stenosis_50pct, symptomatic_PAD_with_ABI_less_than_0.85, peripheral_arterial_revascularization, and amputation_due_to_atherosclerotic_disease)
On guideline-directed medical therapy (antiplatelet (aspirin, clopidogrel, ticagrelor, aspirin-dipyridamole), statin (HMG-CoA reductase inhibitor), and blood pressure medication (ACEi, ARB, or beta blocker))

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction — Initial Approval

All of:

Age >= 18 years
BMI >= 27 kg/m² (or >= 25 kg/m² if Asian)
Established cardiovascular disease (prior MI, prior stroke [ischemic or hemorrhagic], carotid artery stenosis ≥50%, or symptomatic PAD with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
History of and continued use of, or contraindication to, ALL GDMT: antiplatelet agent (unless history of hemorrhagic stroke), statin, and blood pressure medication (ACEi, ARB, or beta blocker)
Used in combination with reduced calorie diet and increased physical activity
No concurrent use of another GLP-1 receptor agonist or GLP-1/GIP receptor agonist

Documentation to bring

Documentation of age >= 18 years
Baseline BMI documentation (>= 27 kg/m² general, or >= 25 kg/m² for Asian patients)
Documentation of qualifying established CVD event (prior MI, prior stroke, carotid artery stenosis ≥50%, or symptomatic PAD with ABI <0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
Documentation of current GDMT use or clinical reason GDMT is contraindicated: antiplatelet agent, statin, and blood pressure medication (ACEi, ARB, or beta blocker)
Documentation that Wegovy will be used with reduced calorie diet and increased physical activity
Confirmation of no concurrent GLP-1 receptor agonist or GLP-1/GIP receptor agonist use

Approval and renewal

To renew, the plan looks for Renewal requires: (1) confirmed cardiovascular disease (prior MI, prior stroke, carotid artery stenosis ≥50%, or symptomatic PAD); (2) continued use with reduced calorie diet and increased physical activity; (3) no concurrent GLP-1 or GLP-1/GIP agonist; (4) continued history of use or contraindication to GDMT (antiplatelet, statin, blood pressure medication). BMI threshold and age are NOT re-verified at renewal.

Not covered when

Concurrent use of another GLP-1 receptor agonist (liraglutide, exenatide, semaglutide other products) or GLP-1/GIP receptor agonist (tirzepatide products)

Policy note: GDMT antiplatelet requirement has an exception: if the patient has a history of hemorrhagic stroke, antiplatelet is not required. At renewal, the BMI threshold is not re-verified — only CV disease confirmation, GDMT, diet/activity, and no concurrent GLP-1 are checked.

Policy effective June 1, 2026 · verified June 5, 2026 · source: Standard-Commercial-Guidelines-6-1-26-EXCERPTED.pdf

Kaiser Permanente Northern California coverage for Wegovy (Heart Disease Risk Reduction)