UnitedHealthcare · Heart Disease Risk Reduction

UnitedHealthcare coverage for Wegovy (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 45 and older
BMI of 27 or higher
A1C no higher than 6.5%
Established cardiovascular disease (MI, ischemic_stroke, hemorrhagic_stroke, and PAD)
On guideline-directed medical therapy (statin, PCSK9i, beta_blocker, ACE_inhibitor, ARB, ARNI, and antiplatelet)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

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

Documentation to bring

Medical records documenting BMI >= 27 kg/m2
Medical records documenting established cardiovascular disease (prior MI, prior ischemic or hemorrhagic stroke, or symptomatic PAD with qualifying evidence)
For PAD: ABI < 0.85 at rest, peripheral arterial revascularization procedure record, or amputation due to atherosclerotic disease
Documentation of current use of required GDMT medications (cholesterol-lowering, beta-blocker [for MI], ACE-I/ARB/ARNI, antiplatelet) or clinical reason for contraindication/intolerance for each class
HgA1c result confirming <= 6.5% and no diabetes diagnosis
Confirmation of absence of NYHA Class IV heart failure

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Reauthorization requires: (1) continued use with reduced calorie diet and increased physical activity, AND (2) absence of diabetes diagnosis or HgA1c > 6.5%, AND absence of NYHA Class IV heart failure. BMI requirement is NOT re-checked at reauthorization (removed in 2/2026 update). GDMT requirement is NOT re-checked at reauthorization. Age requirement is NOT re-checked at reauthorization.

Not covered when

Diagnosis of diabetes or HgA1c > 6.5%
New York Heart Association (NYHA) Class IV heart failure

Policy note: Both Wegovy injection and Wegovy tablets are covered for this indication. Reauthorization criteria do NOT re-check BMI, age, GDMT use, or documented CV event — only ongoing absence of diabetes/high A1C, absence of NYHA Class IV heart failure, and continued diet/exercise are required at renewal. Beta-blocker requirement (carvedilol, metoprolol, or bisoprolol) applies only to patients with history of MI, not stroke or PAD.

Policy effective May 1, 2026 · verified June 2, 2026 · source: PA-Non-Formulary-Wegovy.pdf

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Covered with requirements

What you need to qualify

Age 45 and older
BMI of 27 or higher
A1C no higher than 6.5%
Established cardiovascular disease (MI, ischemic_stroke, hemorrhagic_stroke, and PAD)
On guideline-directed medical therapy (statin, PCSK9i, beta_blocker, ACE_inhibitor, ARB, ARNI, and antiplatelet)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

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

Documentation to bring

Medical records documenting BMI >= 27 kg/m2
Medical records documenting established cardiovascular disease (prior MI, prior ischemic or hemorrhagic stroke, or symptomatic PAD with qualifying evidence)
For PAD: ABI < 0.85 at rest, peripheral arterial revascularization procedure record, or amputation due to atherosclerotic disease
Documentation of current use of required GDMT medications (cholesterol-lowering, beta-blocker [for MI], ACE-I/ARB/ARNI, antiplatelet) or clinical reason for contraindication/intolerance for each class
HgA1c result confirming <= 6.5% and no diabetes diagnosis
Confirmation of absence of NYHA Class IV heart failure

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Reauthorization requires: (1) continued use with reduced calorie diet and increased physical activity, AND (2) absence of diabetes diagnosis or HgA1c > 6.5%, AND absence of NYHA Class IV heart failure. BMI requirement is NOT re-checked at reauthorization (removed in 2/2026 update). GDMT requirement is NOT re-checked at reauthorization. Age requirement is NOT re-checked at reauthorization.

Not covered when

Diagnosis of diabetes or HgA1c > 6.5%
New York Heart Association (NYHA) Class IV heart failure

Policy effective May 1, 2026 · verified June 2, 2026 · source: PA-Non-Formulary-Wegovy.pdf

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