Employer and ACA Marketplace: Not covered. Use for weight loss (no MACE or MASH diagnosis) is explicitly excluded. Diagnosis of type 1 or type 2 diabe...
Full requirements: Wegovy for Weight Loss (2 plan types)›
Applies to Employer and ACA Marketplace plans.
Not covered
Use for weight loss (no MACE or MASH diagnosis) is explicitly excluded. Diagnosis of type 1 or type 2 diabetes without MACE or MASH is also excluded.
Policy note: Wegovy is explicitly excluded for weight loss unless the patient has a qualifying MACE or MASH diagnosis. Type 1 or type 2 diabetes without MACE or MASH also does not qualify.
Policy effective June 22, 2026 · verified June 10, 2026 · source: Cw577pv8jf
· View policy document (PDF)
Full requirements: Wegovy for Heart Disease Risk Reduction (2 plan types)›
Applies to Employer and ACA Marketplace plans.
Covered with requirements
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction (MACE)
All of:
Documented history of prior cardiovascular event (MI, ischemic or hemorrhagic stroke, symptomatic PAD with ABI <0.85, or history of peripheral arterial revascularization)
BMI ≥ 27 kg/m2
Used in combination with caloric restriction, increased physical activity, and behavioral modification
Documented intolerance or treatment failure with formulary alternatives for cardiovascular disease (lipid lowering agents, anti-platelets and anticoagulants, antihypertensive agents)
Prescribed by or in consultation with a cardiologist
Documentation to bring
Documented history of prior qualifying cardiovascular event (MI, stroke, symptomatic PAD with ABI <0.85, or peripheral arterial revascularization procedure)
Baseline BMI ≥ 27 kg/m2
Documentation of intolerance or treatment failure with formulary alternatives for CV disease: lipid lowering agents, anti-platelets/anticoagulants, and antihypertensive agents
Prescriber attestation or consultation note from cardiologist
For reauthorization: documentation of treatment success for MACE risk reduction
Approval and renewal
Initial approval: 12 months
Renewal: every 12 months
Renewal: Documentation of treatment success (MACE risk reduction). BMI, CV event history, and GDMT requirements are not explicitly re-verified at reauthorization — only treatment success documentation is required.
Policy note: PAD qualifying event requires symptomatic PAD such as intermittent claudication with ankle-brachial index (ABI) less than 0.85 at rest, OR history of peripheral arterial revascularization procedure. Policy does not explicitly state whether T2DM co-diagnosis is permitted or excluded for this indication — unlike a strict non-diabetic CV indication. The document does not exclude diabetes patients from this pathway. GDMT step therapy requires documented intolerance or failure with all three classes: lipid lowering agents, anti-platelets/anticoagulants, and antihypertensive agents.
Policy effective June 22, 2026 · verified June 10, 2026 · source: Cw577pv8jf
· View policy document (PDF)
Full requirements: Wegovy for Liver Disease (MASH) (2 plan types)›
Applies to Employer and ACA Marketplace plans.
Covered with requirements
Qualification pathways
You can qualify through any one of these.
MASH Initial Approval
All of:
Diagnosis of noncirrhotic NASH or MASH with moderate to advanced (F2 to F3) liver fibrosis confirmed by one of: FAST score, MAST score, MEFIB (FIB-4 ≥1.6 and MRE ≥3.3 kPa), or liver biopsy
Other causes for liver steatosis have been ruled out (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
Baseline lab values for AST and ALT documented
Documented treatment failure (or intolerable adverse event) with at least 12 weeks of one of: Mounjaro, Ozempic, Trulicity, liraglutide, or Rybelsus
Documentation of abstinence from alcohol consumption
Documentation of comprehensive comorbidity management including: diet and exercise for weight management, and medications to manage associated comorbid conditions (thyroid disease [must not have active disease], diabetes, dyslipidemia, hypertension, or cardiovascular conditions)
Prescribed by or in consultation with a gastroenterologist or hepatologist
Documentation to bring
Diagnosis of noncirrhotic MASH/NASH confirmed by one of: FAST score, MAST score, MEFIB (FIB-4 ≥1.6 and MRE ≥3.3 kPa), or liver biopsy — must demonstrate F2-F3 fibrosis
Documentation that other causes of liver steatosis have been ruled out (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
Baseline AST and ALT lab values
Documentation of treatment failure or intolerable adverse event with at least 12 weeks of one of: Mounjaro, Ozempic, Trulicity, liraglutide, or Rybelsus
Documentation of abstinence from alcohol consumption
Documentation of comprehensive comorbidity management (diet/exercise for weight management; medications for thyroid disease, diabetes, dyslipidemia, hypertension, or cardiovascular conditions as applicable)
Prescriber attestation or consultation note from gastroenterologist or hepatologist
For reauthorization: documentation of disease responsiveness (improvement or stability in ALT/AST or fibrosis by non-invasive test)
Approval and renewal
Initial approval: 12 months
Renewal: every 12 months
Renewal: Documentation of disease responsiveness to therapy based on improvements or stability in laboratory results (such as ALT and AST) or fibrosis as evaluated by a non-invasive test. Prior GLP-1 failure, abstinence from alcohol, and specialist consultation are not explicitly re-verified at reauthorization.
Not covered when
Cirrhotic MASH (must be noncirrhotic)
Active thyroid disease
Must not have other causes of liver steatosis (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
Policy note: MASH confirmation must use ONE of: (1) FAST score from FibroScan-AST, (2) MAST score from MRI-PDFF + MRE + serum AST, (3) MEFIB index (FIB-4 ≥1.6 AND MRE ≥3.3 kPa), or (4) liver biopsy. Liver biopsy is also required if non-invasive testing is inconclusive or other causes of liver disease have not been ruled out. The prior GLP-1 trial requirement specifies 12 weeks (84 days). The policy explicitly excludes use for weight loss or type 1/type 2 diabetes without a qualifying MACE or MASH diagnosis. No lookback periods are specified for the confirmation tests. No explicit alcohol gram limits are stated; abstinence is required.
Policy effective June 22, 2026 · verified June 10, 2026 · source: Cw577pv8jf
· View policy document (PDF)
No. PacificSource Health's policies on file exclude Wegovy for weight loss on Employer and ACA Marketplace plans.
How long does a Wegovy approval last with PacificSource Health?
Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. Initial approval: 12 months. Renewal: every 12 months. Liver Disease (MASH) — Applies to Employer and ACA Marketplace plans. Initial approval: 12 months. Renewal: every 12 months.
What does PacificSource Health require to renew Wegovy?
Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. Documentation of treatment success (MACE risk reduction). BMI, CV event history, and GDMT requirements are not explicitly re-verified at reauthorization — only treatment success documentation is required. Liver Disease (MASH) — Applies to Employer and ACA Marketplace plans. Documentation of disease responsiveness to therapy based on improvements or stability in laboratory results (such as ALT and AST) or fibrosis as evaluated by a non-invasive test. Prior GLP-1 failure, abstinence from alcohol, and specialist consultation are not explicitly re-verified at reauthorization.
How current is this information?
The oldest review date among the policies on this page is June 10, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.
