PacificSource Health · Heart Disease Risk Reduction
PacificSource Health coverage for Wegovy (Heart Disease Risk Reduction)
Employer / Commercial Insurance
Covered with requirements
What you need to qualify
Age 18 and older
BMI of 27 or higher
Prescribed by or in consultation with a specialist
Established cardiovascular disease (MI, stroke, PAD, and peripheral_arterial_revascularization)
On guideline-directed medical therapy (lipid_lowering_agents, anti-platelets, anticoagulants, and antihypertensive_agents)
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
To renew, the plan looks for 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
ACA Marketplace
Covered with requirements
What you need to qualify
Age 18 and older
BMI of 27 or higher
Prescribed by or in consultation with a specialist
Established cardiovascular disease (MI, stroke, PAD, and peripheral_arterial_revascularization)
On guideline-directed medical therapy (lipid_lowering_agents, anti-platelets, anticoagulants, and antihypertensive_agents)
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
To renew, the plan looks for 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
