Prior authorization required — submit specialty-specific request and required records

Submit a prior authorization request with the required clinical documentation and ensure the initial prescriber is within the approved specialty or in consultation with one. Initial prescribers must be a cardiologist, endocrinologist, lipid specialist, cardiometabolic specialist, or a primary care physician in consultation with one of these for cardiovascular risk reduction; for MASH prescribers must be a gastroenterologist, hepatologist, cardiometabolic specialist, or primary care in consultation with one of these.

• Required documentation for cardiovascular risk reduction: chart notes/claims supporting existing CVD, current BMI within 90 days, and evidence of concomitant guideline-directed medical therapies (antiplatelet, lipid-lowering, antihypertensive).
• Required documentation for MASH: chart notes/medical records documenting MASH diagnosis with one record sufficient (e.g., liver biopsy, FAST, MAST, MEFIB).
• Prescriber specialties (initial requests): Cardiologist; Endocrinologist; Lipid specialist; Cardiometabolic specialist; Primary care physician (in consultation) for CVD. For MASH: Gastroenterologist; Hepatologist; Cardiometabolic specialist; Primary care physician (in consultation).

Prior authorization requirement — member must meet all clinical criteria

Prior authorization will be approved only if the member meets all listed clinical criteria for the requested supplemental indication; approvals may be subject to FDA dosing and the policy's quantity limits.

• For CVD: documentation of established CVD, BMI ≥27 kg/m2, absence of diabetes (HbA1c ≥6.5%) and recent pancreatitis, and receipt of standard CVD therapies (or documented intolerance/contraindication).
• For MASH: documentation of positive clinical response and absence of progression to cirrhosis/hepatic decompensation/HCC; not used with another GLP‑1.
• Approvals may be limited to dosing per FDA label and subject to quantity limits.

Document ongoing standard secondary prevention therapies or reasons they are not used

For cardiovascular indications, confirm the member is receiving guideline-directed secondary prevention therapies (antiplatelet, lipid-lowering agent, and antihypertensive) or document intolerance/contraindication to these classes.

• Policy requires concomitant treatment with antiplatelet (e.g., aspirin, P2Y12 inhibitors), lipid-lowering (e.g., statin, ezetimibe, PCSK9 inhibitors), and antihypertensive therapy (e.g., beta-blocker, ACE inhibitor, or ARB) unless inadequate response, intolerance, or contraindication is documented.
• If the member has inadequate response/intolerance/contraindication to agents in these classes, document the medical justification per the policy.

No concomitant GLP‑1 agonist; use with lifestyle modifications

Do not combine Wegovy with another GLP‑1 receptor agonist and ensure the medication is used alongside lifestyle modifications (diet, exercise, behavioral support).

• Policy excludes coadministration with other semaglutide-containing products or any other GLP‑1 receptor agonist.
• For MASH and CVD indications, the requested medication must be used with healthy lifestyle modifications (dietary/caloric restriction, exercise, behavioral support).

Required documentation — submit diagnosis, recent BMI, concomitant therapies, and MASH confirmation

Provide the chart notes, claims, and test results listed in the policy: for cardiovascular risk reduction include documentation of established CVD, current BMI within 90 days, and evidence of concomitant guideline-directed therapies; for MASH include diagnostic confirmation (liver biopsy, FAST, MAST, or MEFIB) and for continuation supply records demonstrating positive clinical response.

• Cardiovascular documentation: chart notes/claims showing prior MI, prior stroke, or symptomatic PAD; BMI measurement within 90 days; evidence of antiplatelet, lipid-lowering, and antihypertensive use.
• MASH documentation: one diagnostic record confirming F2–F3 fibrosis (liver biopsy, FAST, MAST, or MEFIB) and for continuation, medical records demonstrating improved ALT or reduced liver fat by MRI‑PDFF or FibroScan CAP.

Required clinical and adherence documentation for continuation and supplemental coverage

For MASH continuation and for cardiovascular supplemental coverage, include clinical response and adherence evidence: show improved liver tests or imaging for MASH and claims-based adherence (≥80% fill rate) and baseline BMI ≥27 kg/m2 for cardiovascular supplemental coverage.

• MASH continuation: medical records demonstrating positive clinical response (e.g., improved ALT, reduction in liver fat by MRI‑PDFF or FibroScan CAP).
• Cardiovascular supplemental coverage: evidence of ≥80% medication fill rate and baseline BMI ≥27 kg/m2 as documented within the medical record or claims.

Insufficient documentation may lead to denial

Failure to submit the required documentation (e.g., evidence of established CVD, recent BMI, evidence of guideline-directed therapies, or diagnostic confirmation of MASH) may result in denial of the request.

• Missing chart notes/claims supporting existing CVD, BMI within 90 days, or proof of concomitant guideline-directed therapies can lead to an adverse determination.
• For MASH, absence of a supporting diagnostic record (liver biopsy, FAST, MAST, MEFIB) or lack of records showing positive clinical response for continuation may result in denial.

Denial risk — not medically necessary if criteria unmet

Wegovy will be considered not medically necessary and the prior authorization denied when the member does not meet the policy criteria (e.g., not meeting established CVD or MASH requirements, ongoing use of another GLP‑1 agonist, or lack of required documentation).

• Policy explicitly states Wegovy is not medically necessary for members who do not meet the criteria set forth in the policy.
• Use in combination with another GLP‑1 receptor agonist is excluded and is a basis for noncoverage.