Semaglutide (Wegovy)
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Defines medical necessity criteria, prior authorization requirements, and coverage limitations for Wegovy (semaglutide) injection and tablets for Centene lines of business (HIM, Medicaid). Applies to prescribers requesting coverage under Centene-affiliated health plans.
Wegovy is now FDA approved for MASH and criteria were updated per FDA labeling including revised biopsy lookback period and imaging-based biomarker examples.
Revised biopsy lookback period from 6 months to 3 years per AASLD guidance and replaced FibroScan with VCTE as the imaging-based example.
For members with concurrent T2DM, added trial options of Rybelsus, Trulicity and Victoza as alternatives.
For continued therapy, moved location of criterion regarding tolerance to maintenance dose of ≥1.7 mg once weekly after at least 17 weeks of Wegovy therapy and revised renewal language to 'after at least 12 months of therapy'.
Coverage Criteria for Wegovy (semaglutide)
Initial Approval — Cardiovascular Event Prevention
Covered when ALL of the following are met
See Section V for dose escalation and Appendix D for cardiovascular standard of care; step therapy exemption for Illinois HIM per IL HB 5395 (chunk 5).
Initial Approval — MASH
Covered when ALL of the following are met
Intolerance to common GLP-1 adverse effects (e.g., GI symptoms) is not acceptable medical justification for switching (chunk 8).
Continued Therapy — Cardiovascular Event Prevention
Covered for renewal when ALL of the following are met
Approval duration for continued therapy: 12 months (chunk 11).
Continued Therapy — MASH
Covered for renewal when ALL of the following are met
Approval duration for continued therapy: 12 months (chunk 13).
Not Authorized / Exclusions
Coverage is NOT authorized for the following
See policy appendices and referenced off-label/non-formulary policies for further guidance (chunks 7, 12, 16).
Indication, dosing, and therapy continuation
Policy contains indication-specific criteria and required trials/standards of care for approval
See individual indication sections for full medical necessity criteria (chunks 25, 31, 33).
Continued therapy timing revised: renewals after at least 12 months of therapy; document dosing regimen and formulation (chunk 25, and reviews/updates in chunk 31/33).
Use of Wegovy for the treatment of weight management is a benefit exclusion and will not be authorized under this policy. Requests for Wegovy where the primary indication is weight management should be denied in accordance with the exclusion language.
For the indication of metabolic dysfunction-associated steatohepatitis (MASH), Wegovy must not be prescribed concurrently with Rezdiffra. Concurrent use of Wegovy and other semaglutide-containing products or any other GLP-1 receptor agonist(s) is also prohibited for MASH requests.
Contraindications include a personal or family history of medullary thyroid carcinoma (MTC) or a diagnosis of multiple endocrine neoplasia type 2 (MEN 2). The policy also lists known hypersensitivity to semaglutide or any Wegovy excipient as a contraindication; prescribers should not initiate therapy in these patients.
Requests that exceed the labeled dose escalation or maintenance schedules are not supported. For injection, escalation follows 0.25 mg wk1–4; 0.5 mg wk5–8; 1 mg wk9–12; 1.7 mg wk13–16; 2.4 mg wk17+, with maintenance doses not to exceed 2.4 mg once weekly. For tablets, escalation and maintenance follow the labeled schedule up to 25 mg/day with a maximum of 1 tablet per day. Concurrent use of Wegovy with other semaglutide-containing products or other GLP-1 receptor agonists is not permitted and may be considered not medically necessary.
The inclusion or exclusion of procedure, diagnosis, or billing codes in this policy is for informational purposes only and does not guarantee coverage. Coverage determinations require that all applicable clinical criteria are met; failure to meet the clinical criteria in this policy may render the treatment not covered by the plan.
Coding and Drug/HCPCS References
| Ozempic | semaglutide SC once weekly (alternative agent) |
| Rybelsus | semaglutide oral tablet (alternative agent) |
| Trulicity | dulaglutide SC once weekly (alternative agent) |
| Victoza | liraglutide SC (alternative agent) |
| C9399 | Unclassified drugs or biologicals |
| J3490 | Unclassified drugs |
Provider Actions, Prior Authorization, and Documentation
Prior authorization required with supporting clinical documentation
Prior authorization is required. Submit clinical documentation demonstrating that the member meets all initial approval criteria (e.g., diagnosis, BMI, prior therapy where applicable, participation in a physician-directed weight loss program, baseline body weight, and dosing limits).
- Documentation examples: office chart notes, lab results, other clinical information showing criteria met
Document ≥3-month trials of specified GLP‑1 agents for concurrent T2DM/MASH
For members with concurrent T2DM or MASH, document trials of the specified diabetic GLP-1 agents (Ozempic or Rybelsus, Trulicity, and Victoza) of at least 3 consecutive months each unless contraindicated or clinically significant adverse effects occur.
- Trials must be documented unless contraindicated or intolerable adverse effects occur
- Illinois HIM requests are exempt from these step therapy requirements per IL HB 5395 (see policy notes)
Step therapy requirements and Illinois HIM bypass
Step therapy requirements include documented trials of alternative GLP‑1 agents; Illinois HIM requests are exempt from step therapy per IL HB 5395 as noted in the policy.
- Added trial options: Rybelsus, Trulicity, Victoza
- Step therapy bypass applied for Illinois HIM effective 1/1/2026 per IL HB 5395
Submit office notes, labs, and attestations showing all approval criteria met
Provider must submit documentation (office chart notes, labs, or other clinical information) showing the member meets all approval criteria, including baseline and current body weight in kg, enrollment in and continuation of a physician-directed weight loss program, and prescriber attestations of standard‑of‑care management.
- Include evidence of enrollment in a physician-directed weight loss program for ≥6 months and plan to continue while on Wegovy
- Include prescriber attestation of cardiovascular or MASH standard‑of‑care management where applicable
Provide fibrosis staging documentation for MASH (biopsy or serum + imaging)
For MASH requests, submit documentation confirming stage F2–F3 fibrosis by either a liver biopsy within the last 3 years or both a serum‑based and an imaging‑based assessment within the last 6 months (examples provided in Appendix E).
- Serum-based examples: FIB-4, NAFLD fibrosis score (NFS), ELF
- Imaging-based examples: VCTE, MRE, MRI-PDFF (see Appendix E for MAST/FAST/MEFIB examples)
Document dosing regimen, formulation, and adherence
Document the requested dosing regimen and formulation (injectable pens or tablets) and evidence of adherence to the labeled escalation and maintenance schedules; specify the exact doses prescribed (e.g., 0.25, 0.5, 1, 1.7, 2.4 mg pens or 1.5, 4, 9, 25 mg tablets).
- Injection escalation: wk1–4 0.25 mg; wk5–8 0.5 mg; wk9–12 1 mg; wk13–16 1.7 mg; wk17+ 2.4 mg
- Tablet escalation: Days1–30 1.5 mg; Days31–60 4 mg; Days61–90 9 mg; Days91+ 25 mg (max 1 tablet/day)
Requests for weight management will be denied (benefit exclusion)
Requests for Wegovy for weight management will be denied because use for weight management is a benefit exclusion under this policy.
- Weight management indication is explicitly excluded and not authorized
Denial risk for exceeding dosing limits or concurrent GLP‑1 use
Requests that exceed the policy's labeled escalation or maintenance dosing schedules, or requests that involve concurrent use with other semaglutide-containing products or other GLP‑1 receptor agonists, will be denied.
- Maximum weekly dose for injection is 2.4 mg; tablet maintenance is 25 mg/day (max 1 tablet/day)
- Concurrent prescribing with Rezdiffra or other semaglutide-containing products/GLP‑1 agonists is prohibited
Coding lists are informational — improper coding or missing documentation may cause denial
Inclusion or exclusion of codes in this policy is informational and does not guarantee coverage; improper coding or failure to document that the member meets the policy's clinical criteria may result in claim denial.
- Providers should reference up-to-date professional coding guidance before claim submission
Background on Semaglutide (Wegovy)
Semaglutide (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist with multiple FDA indications relevant to this policy. It is indicated to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and overweight/obesity, to reduce and maintain weight (including pediatric patients aged ≥12 years for the injectable formulation), and to treat metabolic dysfunction-associated steatohepatitis (MASH) with stage F2–F3 fibrosis. Concomitant use with other semaglutide-containing products or GLP-1 receptor agonists is not recommended and is restricted by this policy.
Definitions and Key Terms
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