Molina Healthcare coverage for Wegovy (Heart Disease Risk Reduction)

In states where weight loss drugs are a benefit exclusion, Wegovy (semaglutide) injection and tablets are considered a benefit exclusion for ALL indications, including but not limited to weight reduction to lower risk for repeat cardiovascular event in individuals with history of prior heart attack or stroke. Weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage.

Exceptions

• California: See Weight Management Therapy CA MMKP C28425-A for state-specific criteria.
• New Mexico: See Weight Management Therapy NM MMKP C29220-A for state-specific criteria.

Policy note: The policy explicitly states Wegovy is a benefit exclusion for ALL indications including weight reduction to lower CV risk. The CV risk reduction indication is not separately adjudicated — it is swept under the blanket weight-loss benefit exclusion for Marketplace. The background section describes the SELECT trial population (adults ≥45 years, BMI ≥27, established CVD including prior MI, stroke, or PAD, and no T1D or T2D) but these are informational only and do not constitute coverage criteria since the indication is excluded.

Policy effective May 30, 2026 · verified June 11, 2026 · source: D84835628C9549BFB30D1D6F9EDBAC8E.ashx