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PacificSource Health

Does PacificSource Health cover Wegovy for Heart Disease Risk Reduction?

Yes. PacificSource Health covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 27 or higher. Other policy requirements and your plan's benefits also apply.

Policy document

  • Employer and ACA Marketplace: Covered with requirements. See the qualification pathways below.

Earliest policy review June 10, 2026. How we verify · Check your exact plan

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)

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Questions people ask
Does PacificSource Health cover Wegovy?
Yes. PacificSource Health covers Wegovy for heart disease risk reduction with prior authorization if your BMI is 27 or higher. Other policy requirements and your plan's benefits also apply.
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.
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.
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.

Also under PacificSource Health: Mounjaro, Ozempic

Wegovy under other plans: Kaiser Permanente Northwest, Oregon Medicaid, Regence, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid

All insurance plans · All medications

Summary of PacificSource Health's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.