CurrentCignaPolicy BEO013

Wegovy Tablet Benefit Exclusion Overrides Policy BMI ≥35

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This policy governs benefit-exclusion overrides and medical-necessity authorization for Wegovy (semaglutide) tablets in adults seeking weight loss or reduction of major adverse cardiovascular events. Coverage is limited to specified FDA-approved indications and requires applicable clinical, BMI, treatment-history, and duration criteria.

Policy Summary

PayerCigna

PolicyWegovy Tablet Benefit Exclusion Overrides Policy BMI ≥35

Policy CodePolicy BEO013

Change TypeNew policy

Effective DateSeptember 1, 2026

Last ReviewJul 9, 2026

Next Review DateN/A

Key ActionSubmit the request under the applicable FDA-approved indication and satisfy all criteria for the requested therapy.

SourceLink

POLICY UPDATE CHANGES

This document establishes a new policy authorizing Wegovy tablet coverage for specified weight-loss and cardiovascular-risk-reduction indications.

BMI ≥35Weight-loss pathway without listed comorbidity requirement

BMI ≥27 + 2Alternative weight-loss eligibility pathway

8 monthsInitial weight-loss approval duration

1 year

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CurrentCignaPolicy BEO013

Wegovy Tablet Benefit Exclusion Overrides Policy BMI ≥35

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Get alerted when Policy BEO013 changes without checking for updates manually.

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Policy Summary

PayerCigna

PolicyWegovy Tablet Benefit Exclusion Overrides Policy BMI ≥35

Policy CodePolicy BEO013

Change TypeNew policy

Effective DateSeptember 1, 2026

Last ReviewJul 9, 2026

Next Review DateN/A

Key ActionSubmit the request under the applicable FDA-approved indication and satisfy all criteria for the requested therapy.

SourceLink

POLICY UPDATE CHANGES

This document establishes a new policy authorizing Wegovy tablet coverage for specified weight-loss and cardiovascular-risk-reduction indications.

BMI ≥35Weight-loss pathway without listed comorbidity requirement

BMI ≥27 + 2Alternative weight-loss eligibility pathway

8 monthsInitial weight-loss approval duration

1 year

Continuation or cardiovascular-risk-reduction approval duration

≥5% lossContinuation response requirement

90 daysDose escalation to 25 mg

Medical Necessity and Coverage Criteria

Initial Therapy for Adult Weight Loss

Wegovy tablet is medically necessary when ONE of the following FDA-approved indications is met.

Initial therapy for adult weight loss

Eligibility and lifestyle treatment: The patient is at least 18 years of age, has engaged in behavioral modification and dietary restriction for at least 3 months, and will use the medication concomitantly with behavioral modification and a reduced-calorie diet.Age ≥18 years; behavioral modification and dietary restriction ≥3 months
Baseline BMI pathway: The patient had a baseline BMI ≥35 kg/m², OR had a baseline BMI ≥27 kg/m² and at least two listed weight-related comorbidities at baseline or currently.BMI ≥35 kg/m² OR BMI ≥27 kg/m² plus ≥2 comorbidities
Baseline is before any GLP-1 or GLP-1/GIP receptor agonist. Listed comorbidities are hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, and coronary artery disease.

Continuation Therapy

Continuation therapy is covered for an adult currently receiving Wegovy tablet, Wegovy injection, or Wegovy HD injection when ALL of the following are met.

Continuation weight-loss therapy

Age and treatment response: The patient is at least 18 years of age and has lost at least 5% of baseline body weight.Age ≥18 years; weight loss ≥5% of baseline body weight
Baseline refers to the period before any GLP-1 or GLP-1/GIP receptor agonist.
Baseline BMI pathway: The patient had a baseline BMI ≥35 kg/m², OR had a baseline BMI ≥27 kg/m² and at least two listed weight-related comorbidities at baseline or currently.BMI ≥35 kg/m² OR BMI ≥27 kg/m² plus ≥2 comorbidities
Listed comorbidities are hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, and coronary artery disease.

Major Adverse Cardiovascular Event Risk Reduction

Wegovy tablet is medically necessary for major adverse cardiovascular event risk reduction when ALL of the following are met.

Cardiovascular-risk-reduction indication

Adult with overweight or obesity: The patient is at least 18 years of age and had a baseline BMI ≥27 kg/m².Age ≥18 years; baseline BMI ≥27 kg/m²
Baseline is before any GLP-1 or GLP-1/GIP receptor agonist.
Established cardiovascular disease evidence: The patient has had a prior myocardial infarction, a prior stroke, or symptomatic peripheral arterial disease evidenced by intermittent claudication with ankle-brachial index <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease.Prior myocardial infarction or stroke, or qualifying symptomatic peripheral arterial disease
A transient ischemic attack does not qualify as a prior stroke.

Concomitant use of Wegovy tablet with another GLP-1 receptor agonist or a GLP-1/GIP receptor agonist is not medically necessary.

Any use of Wegovy tablet other than the policy’s specified covered FDA-approved indications is not medically necessary. The list of noncovered uses may not be all-inclusive and may be updated as new published data become available.

Wegovy tablet is not medically necessary when used concomitantly with another GLP-1 receptor agonist or a GLP-1/GIP receptor agonist.

Wegovy tablet is not medically necessary for any other use that does not meet the policy’s specified FDA-approved indication criteria.

Clinical Thresholds and Authorization Parameters

Adult baseline BMI

BMI ≥35 pathwayBaseline BMI ≥35 kg/m² qualifies for the adult weight-loss pathway.

BMI ≥27 pathwayBaseline BMI ≥27 kg/m² qualifies when the patient has at least two weight-related comorbidities at baseline or currently.

Baseline timingBaseline BMI is measured before any GLP-1 or GLP-1/GIP receptor agonist therapy.

Continuation weight response

Required responseThe patient must have lost ≥5% of baseline body weight.

Age requirementContinuation therapy requires the patient to be ≥18 years of age.

Applicable therapy

Submission and Documentation Guidance

Prior Authorization

Submit Under the Applicable Indication

Submit the request under the applicable FDA-approved indication and document that all requirements for the requested authorization period are met. Coverage may be requested for initial weight-loss therapy, continuation weight-loss therapy, or major adverse cardiovascular event risk reduction in a patient with established cardiovascular disease.

Initial weight-loss therapy: approval for 8 months when all initial-therapy criteria are met.
Continuation weight-loss therapy: approval for 1 year when all continuation criteria are met; patients who have not completed 8 months of initial therapy should be evaluated under the initial-therapy criteria.
Cardiovascular-risk reduction: approval for 1 year when all established-cardiovascular-disease criteria are met.

Documentation Required

Document Clinical Eligibility

Document the clinical information supporting eligibility before submitting authorization. Baseline BMI means the BMI before any GLP-1 or GLP-1/GIP agonist therapy, and the record must support the applicable age, comorbidity, behavioral, dietary, and treatment-history requirements.

Therapeutic Context

Wegovy tablet is a GLP-1 receptor agonist used with a reduced-calorie diet and increased physical activity for long-term weight reduction in adults with overweight and a weight-related comorbidity or with obesity. It is also indicated to reduce major adverse cardiovascular events in adults with established cardiovascular disease and overweight or obesity.

Terms and Clinical Definitions

Adult BMI categories

OverweightBMI ≥25.0 to ≤29.9 kg/m².

Class I obesityBMI ≥30.0 to ≤34.9 kg/m².

Class II obesityBMI ≥35.0 to ≤39.9 kg/m².

Class III obesityBMI ≥40 kg/m².

Baseline

Baseline BMIThe BMI measurement obtained before any GLP-1 agonist, including liraglutide or Wegovy, or any GLP-1/GIP receptor agonist such as Zepbound.

Baseline body weightThe body-weight measurement obtained before any GLP-1 agonist or GLP-1/GIP receptor agonist therapy.

Policy Summary

PayerCigna

PolicyWegovy Tablet Benefit Exclusion Overrides Policy BMI ≥35

Policy CodePolicy BEO013

Change TypeNew policy

Effective DateSeptember 1, 2026

Last ReviewJul 9, 2026

Next Review DateN/A

Key ActionSubmit the request under the applicable FDA-approved indication and satisfy all criteria for the requested therapy.

SourceLink

On This Page

Concurrent lifestyle treatment: The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.

If the patient has not completed 8 months of initial therapy with Wegovy tablet, Wegovy injection, and/or Wegovy HD injection, use the initial-therapy criteria instead.

Required treatment combination: According to the prescriber, the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease and concomitantly with behavioral modification and a reduced-calorie diet.

Continuation criteria apply to patients currently receiving Wegovy tablet, Wegovy injection, or Wegovy HD injection.

Ankle-brachial index

Qualifying thresholdAnkle-brachial index must be <0.85.

Clinical contextThe threshold supports evidence of symptomatic peripheral arterial disease with intermittent claudication.

Alternative evidenceQualifying symptomatic peripheral arterial disease may also be evidenced by peripheral arterial revascularization or amputation due to atherosclerotic disease.

Tablet dose escalation

Escalation periodThe recommended tablet dose-escalation schedule is 90 days.

25 mg dose timingThe 25 mg dose is reached at the start of Day 91.

Maintenance doseFor cardiovascular-risk reduction and weight reduction, the maintenance dose is 25 mg orally once daily.

Patient is at least 18 years of age.
For initial therapy, document at least 3 months of behavioral modification and dietary restriction, plus use with behavioral modification and a reduced-calorie diet.
For weight-loss eligibility, document either baseline BMI of at least 35 kg/m², or baseline BMI of at least 27 kg/m² with at least two qualifying weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease.
For continuation therapy, document at least 5% loss from baseline body weight and continued use with behavioral modification and a reduced-calorie diet.
Identify whether the patient is currently receiving Wegovy tablet, Wegovy injection, or Wegovy HD injection; if 8 months of initial therapy have not been completed, apply the initial-therapy criteria.

Documentation Required

Document Cardiovascular-Risk-Reduction Eligibility

For cardiovascular-risk-reduction requests, document established cardiovascular disease, the qualifying cardiovascular event or condition, and the required accompanying treatment plan.

Patient is at least 18 years of age and had a baseline BMI of at least 27 kg/m² before any GLP-1 or GLP-1/GIP agonist therapy.
Document one qualifying condition: prior myocardial infarction; prior stroke (not a transient ischemic attack); or symptomatic peripheral arterial disease.
For symptomatic peripheral arterial disease, document at least one of the following: intermittent claudication with ankle-brachial index less than 0.85; peripheral arterial revascularization; or amputation due to atherosclerotic disease.
Document that the prescriber will use the medication with optimized pharmacotherapy for established cardiovascular disease and with behavioral modification and a reduced-calorie diet.

Denial Risk

Avoid Denial Conditions and Prohibited Concomitant Use

Authorization may be denied when the patient does not meet the indication-specific requirements or when the medication is used in a manner excluded by the policy. Ensure the submitted record supports every applicable threshold, duration, response, and concomitant-use requirement.

Denial risk includes age under 18 years, failure to meet the applicable baseline BMI threshold, or failure to document at least two qualifying comorbidities when baseline BMI is at least 27 kg/m² but less than 35 kg/m².
For initial weight-loss therapy, failure to document at least 3 months of behavioral modification and dietary restriction or planned use with behavioral modification and a reduced-calorie diet may result in denial.
For continuation therapy, failure to document at least 5% loss from baseline body weight, the required treatment duration, or continued behavioral and dietary intervention may result in denial.
For cardiovascular-risk reduction, failure to document established cardiovascular disease and a qualifying myocardial infarction, stroke, or symptomatic peripheral arterial disease criterion may result in denial; a transient ischemic attack does not qualify.
Do not submit for concomitant use of Wegovy tablet with another GLP-1 receptor agonist or a GLP-1/GIP agonist; such use is not recommended and is considered not medically necessary.
Wegovy tablet for uses other than the covered FDA-approved indications is considered not medically necessary.

Billing Rule

Use Supported Diagnosis and Coding

Submit claims using the most appropriate covered diagnosis and procedure codes in effect on the date of submission. Claims for conditions or diagnoses not covered under this policy, or claims not accompanied by applicable covered codes, may be denied as not covered.

Verify that the diagnosis and procedure codes support the applicable covered indication and authorization criteria.
Use the applicable codes as of the effective date of the submission.
Do not bill for an unsupported diagnosis or an indication not covered by this policy.

Use in continuation reviewContinuation weight response is measured against baseline body weight.

Qualifying established cardiovascular disease

Qualifying cardiovascular diseaseEstablished cardiovascular disease may be evidenced by a prior myocardial infarction, a prior stroke, or symptomatic peripheral arterial disease.

Stroke versus TIAA prior stroke qualifies; a transient ischemic attack does not qualify as a prior stroke.

Symptomatic peripheral arterial diseaseEvidence may include intermittent claudication with ankle-brachial index <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease.