You can qualify through any one of these.
CV Risk Reduction — History of MI
All of:
- Treatment requested to reduce risk of major adverse cardiovascular events
- Patient age >= 45 years
- BMI >= 27 kg/m2 (documented in medical records)
- Prior myocardial infarction (MI) documented in medical records
- Used in combination with reduced calorie diet and increased physical activity
- No diagnosis of diabetes and HgA1c <= 6.5%
- No New York Heart Association class IV heart failure
- On cholesterol-lowering medication (statin or PCSK9i) unless contraindicated or intolerant
- On beta-blocker (carvedilol, metoprolol, or bisoprolol) unless contraindicated or intolerant
- On ACE-I, ARB, or ARNI unless contraindicated or intolerant
- On antiplatelet therapy (aspirin or clopidogrel) unless contraindicated or intolerant
CV Risk Reduction — History of Ischemic or Hemorrhagic Stroke
All of:
- Treatment requested to reduce risk of major adverse cardiovascular events
- Patient age >= 45 years
- BMI >= 27 kg/m2 (documented in medical records)
- Prior ischemic or hemorrhagic stroke documented in medical records
- Used in combination with reduced calorie diet and increased physical activity
- No diagnosis of diabetes and HgA1c <= 6.5%
- No New York Heart Association class IV heart failure
- On cholesterol-lowering medication (statin or PCSK9i) unless contraindicated or intolerant
- On ACE-I, ARB, or ARNI unless contraindicated or intolerant
- On antiplatelet therapy (aspirin or clopidogrel) unless contraindicated or intolerant
CV Risk Reduction — Symptomatic Peripheral Arterial Disease (PAD)
All of:
- Treatment requested to reduce risk of major adverse cardiovascular events
- Patient age >= 45 years
- BMI >= 27 kg/m2 (documented in medical records)
- Used in combination with reduced calorie diet and increased physical activity
- No diagnosis of diabetes and HgA1c <= 6.5%
- No New York Heart Association class IV heart failure
- On cholesterol-lowering medication (statin or PCSK9i) unless contraindicated or intolerant
- On ACE-I, ARB, or ARNI unless contraindicated or intolerant
- On antiplatelet therapy (aspirin or clopidogrel) unless contraindicated or intolerant
Plus any one of:
- Intermittent claudication with ankle-brachial index (ABI) < 0.85 at rest
- Peripheral arterial revascularization procedure
- Amputation due to atherosclerotic disease
Policy effective May 1, 2026 · verified June 2, 2026 · source: PA-Non-Formulary-Wegovy.pdf