Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 55 to 74
- BMI of 27 or higher
- Prior trial of another GLP-1 medication (Ozempic)
- Established cardiovascular disease (STEMI and Type 1 NSTEMI)
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
Initiation for cardiovascular risk reduction
All of:
- No personal or family history of MTC or MEN 2
- Patient does not have diabetes
- BMI >= 27 kg/m2
- Currently following a diet and exercise program
- Age 55 to 74 years
- History of STEMI or Type 1 NSTEMI
- Occurrence of a STEMI or Type 1 NSTEMI while on semaglutide (Ozempic) 2 mg (does not apply to Medicare Part D patients)
Documentation to bring
- Confirmation that patient does not have diabetes
- Documentation of BMI >= 27 kg/m2
- Documentation of patient age (55-74 years)
- Documentation of history of STEMI or Type 1 NSTEMI
- Documentation of occurrence of STEMI or Type 1 NSTEMI while on semaglutide (Ozempic) 2 mg
- Documentation of current diet and exercise program participation
- Confirmation of no personal or family history of MTC or MEN 2
Approval and renewal
- Initial approval: 12 months
Not covered when
- Active diabetes
Policy note: CV risk reduction indication requires the patient to have had a STEMI or Type 1 NSTEMI while specifically on semaglutide (Ozempic) 2 mg — this is a highly specific step-therapy requirement unique to this indication. This requirement does NOT apply to Medicare Part D patients. Non-formulary; covered for 12 months per approval. Continuation criteria for CV indication not explicitly stated in the document.
Policy effective February 5, 2026 · verified June 5, 2026 · source: kp-criteria-wegovy-nw-en-commercial.pdf