Regence · Heart Disease Risk Reduction

Regence coverage for Wegovy (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

BMI of 27 or higher
6 months of a documented diet and exercise program
Established cardiovascular disease (MI, stroke, and PAD)
On guideline-directed medical therapy (blood_pressure_lowering_agents and cholesterol_lowering_agents)
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

MACE secondary prevention

All of:

BMI >= 27 kg/m2
No diagnosis of type 2 diabetes mellitus (T2DM excluded per SELECT trial population)
Attestation that patient will use optimized pharmacotherapy (blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with requested agent
Attestation medication will be used with lifestyle modification
Clinical documentation (e.g., chart notes) confirming all criteria

Plus any one of:

Myocardial infarction
Stroke
Symptomatic peripheral artery disease as evidenced by intermittent claudication with ankle-brachial index < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

Documentation to bring

Clinical documentation (e.g., chart notes) confirming diagnosis of cardiovascular disease — at least one of: prior MI, prior stroke, or symptomatic PAD (intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)
Documentation of BMI >= 27 kg/m2
Attestation that patient does NOT have type 2 diabetes mellitus
Attestation that patient will use optimized pharmacotherapy (blood pressure and cholesterol lowering agents) for established CVD in combination with requested agent
Attestation that medication will be used with lifestyle modification
For continuation: attestation that patient continues to use optimized pharmacotherapy for established CVD

Quantity limits

all strengths - injection — 4 pens per 28 days
all strengths - tablet — 30 tablets per 30 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Attestation that the patient will continue to use optimized pharmacotherapy (such as blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with the requested agent. T2DM exclusion and GDMT attestation requirement are re-verified at continuation.

Not covered when

Type 2 diabetes mellitus (patients with T2DM were excluded from SELECT trial; Ozempic noted as lower-cost alternative for T2DM patients)
NYHA class IV heart failure
Primary prevention (no established CVD) — efficacy unknown
Co-administration with other weight loss medications considered investigational
Diabetic ketoacidosis (DKA)
Type 1 diabetes

Policy note: Indication is MACE secondary prevention only. GDMT attestation is required at both initial and continuation (optimized pharmacotherapy such as blood pressure and cholesterol lowering agents). T2DM is excluded from this indication based on SELECT trial design; the document explicitly notes Ozempic as a lower-cost alternative for T2DM patients. Coverage for MACE prevention is NOT subject to weight loss benefit contract language restriction — it qualifies under standard coverage without the obesity benefit rider requirement. No ABI cutoff is stated in the policy for PAD beyond < 0.85 for intermittent claudication.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

BMI of 27 or higher
6 months of a documented diet and exercise program
Established cardiovascular disease (MI, stroke, and PAD)
On guideline-directed medical therapy (blood_pressure_lowering_agents and cholesterol_lowering_agents)
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

MACE secondary prevention

All of:

Clinical documentation (such as chart notes) confirming established cardiovascular disease
BMI >= 27 kg/m2
Attestation that patient will use optimized pharmacotherapy (such as blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with Wegovy
Attestation that medication will be used with lifestyle modification
Patient does NOT have type 2 diabetes (T2DM excluded per SELECT trial)

Plus any one of:

Prior myocardial infarction
Prior stroke
Symptomatic peripheral artery disease as evidenced by intermittent claudication with ankle-brachial index < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

Documentation to bring

Clinical documentation (such as chart notes) confirming established cardiovascular disease (prior MI, stroke, or symptomatic PAD)
For symptomatic PAD: evidence of intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
Documentation of BMI >= 27 kg/m2
Attestation that patient will use optimized pharmacotherapy (blood pressure and cholesterol lowering agents) for established CVD in combination with Wegovy
Attestation that medication will be used with lifestyle modification

Quantity limits

all strengths - injection — 4 pens/28 days
all strengths - tablet — 30 tablets/30 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Attestation that the patient will continue to use optimized pharmacotherapy (such as blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with Wegovy. BMI, CVD diagnosis, and T2DM exclusion are not explicitly re-verified at continuation.

Not covered when

Type 2 diabetes (T2DM) — patients with T2DM were excluded from the SELECT trial; policy notes Ozempic as a lower-cost option for T2DM patients needing MACE risk reduction
NYHA class IV heart failure
Co-administration with other medications for obesity or overweight (Contrave, Qsymia) is considered investigational
Type 1 diabetes

Policy note: This indication is for secondary prevention of MACE only (not primary prevention). The policy notes that efficacy/safety for primary prevention is unknown. Standard of care for CVD (blood pressure lowering agents, cholesterol lowering agents) must be used in combination. The policy references AHA/ACC guidelines recommending antiplatelets/anticoagulants, beta blockers, and ACE inhibitors/ARBs for secondary prevention, and statins as first-line lipid therapy. Coverage for this indication does NOT appear to require the weight loss benefit rider, unlike the obesity/overweight indication.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf

All Wegovy policies under Regence · Check your card