You can qualify through any one of these.
Initial approval: CV risk reduction in overweight/obesity without diabetes
All of:
- BMI >= 27 kg/m2
- Age >= 18 years
- No diabetes and A1C <= 6.5% (patients with T2DM or A1C >6.5 referred to GLP-1 diabetes policy 27.17.00)
- Established cardiovascular disease with at least one qualifying event
- Concurrent use of at least one secondary prevention medication (antiplatelet, antihypertensive, or lipid-lowering therapy) unless contraindicated or not tolerated
- Semaglutide will not be used in combination with another GLP-1 receptor agonist or DPP4 inhibitor
Plus any one of:
- Prior ischemic or hemorrhagic stroke
- Prior myocardial infarction (MI)
- Symptomatic carotid artery disease (moderate-severe stenosis >50%, revascularization of internal carotid artery, or TIA with focal neurological dysfunction or transient monocular blindness)
- Symptomatic coronary artery disease (coronary stenosis >=50%, symptomatic angina pectoris, or prior coronary revascularization)
- Symptomatic peripheral arterial disease (intermittent claudication with ABI <0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
Reauthorization: CV risk reduction
All of:
- Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
- Patient continues to meet initial criteria 2-6 (age, no T2DM/A1C >6.5%, established CV disease, concurrent secondary prevention medication, no GLP-1/DPP4 combination)
Policy effective February 1, 2026 · verified June 4, 2026 · source: semaglutide.pdf