Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV risk reduction — prior MI or stroke
All of:
- Age ≥ 18 years
- BMI ≥ 27 kg/m2
- Medication used in combination with optimized drug therapy for established cardiovascular disease
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 2.4 mg once weekly (injection) or 25 mg daily (tablets)
- Quantity limited per formulation
- Not used concurrently with other weight loss medications
Plus any one of:
- Prior heart attack
- Prior stroke
CV risk reduction — symptomatic peripheral arterial disease
All of:
- Age ≥ 18 years
- BMI ≥ 27 kg/m2
- History of symptomatic peripheral arterial disease
- Medication used in combination with optimized drug therapy for established cardiovascular disease
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 2.4 mg once weekly (injection) or 25 mg daily (tablets)
- Quantity limited per formulation
- Not used concurrently with other weight loss medications
Plus any one of:
- Intermittent claudication with ankle-brachial index < 0.85
- Peripheral arterial revascularization procedure
- Amputation due to atherosclerotic disease
Documentation to bring
- Office visit notes containing baseline BMI (≥ 27 kg/m2)
- Documentation of qualifying CV event (prior MI, prior stroke, or symptomatic PAD with supporting evidence)
- Documentation of current use of optimized drug therapy for established cardiovascular disease
- Medication dosage documentation
Quantity limits
- 2.4 mg injection — 4 pens per 28 days
- 25 mg tablet — 1 tablet daily
Approval and renewal
- Initial approval: 7 months
- Renewal: every 12 months
- Renewal: Renewal requires re-verification of: age ≥ 18, baseline BMI ≥ 27 kg/m2 (at time of treatment initiation), qualifying CV event (prior MI, stroke, or symptomatic PAD), continued use in combination with optimized CV drug therapy, continued adherence to reduced-calorie diet and increased physical activity, dose 2.4 mg once weekly (injection) or 25 mg daily (tablets), quantity limit 4 pens/28 days (injection) or 1 tablet/day (tablets), and no concurrent weight loss medications.
- Renewal: Staying on a maintenance dose of at least 2.4 mg.
Not covered when
- Concurrent use with other weight loss medications (phentermine, phentermine/topiramate ER, benzphetamine, diethylpropion, phendimetrazine, Alli, Contrave, liraglutide 18 mg/3 mL pen, Qsymia, Saxenda, Wegovy tablets or injection [cross-listed], Xenical, Zepbound)
- All uses other than FDA-approved dosage and administration are considered investigational
- Coverage subject to benefit plan; many plans exclude weight management drugs
- This medical policy does not apply to Medicare Advantage
Policy note: Covers both Wegovy injection (2.4 mg once weekly, 4 pens/28 days) and Wegovy tablets (25 mg daily, 1 tablet/day) for MACE risk reduction indication. PAD qualifying criteria include: intermittent claudication with ABI <0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. The policy does not explicitly exclude diabetes for this indication. Renewal criteria re-verify full initial criteria including CV event qualification and GDMT use.
Policy effective April 1, 2026 · verified June 3, 2026 · source: 5.01.621 · View policy document (PDF)