Semaglutide (Wegovy) - Coverage Criteria
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Defines Health Net coverage criteria, dosing limits, and renewal requirements for Wegovy (semaglutide) for weight management, cardiovascular event prevention, and metabolic dysfunction-associated steatohepatitis (MASH). Affects providers submitting prior authorization and continuations for Health Net members.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Weight Management - Continuation Therapy
Covered when ALL of the following are met
Weight Management - Eligibility and continuity
- Continuity conditions: (a) For a member who has not completed 4 months of initial therapy, refer to Initial Therapy criteria; (b) For members who received compounded semaglutide, samples, or NovoCare® self-pay Wegovy, refer to Initial Therapy criteria; (c) Currently receiving medication via Centene benefit or member has previously met initial approval criteria; (d) New members transitioning from another plan are not grandfathered unless they have at least one indicator of increased cardiovascular risk or another obesity-related medical condition; (e) Current Health Net members transitioning to a new benefit plan with a higher BMI threshold may be grandfathered, or require a new authorization if drug stopped >90 days since last refill (including meeting higher BMI ≥40 if applicable); (f) Member is enrolled in a state/product with continuity of care regulations
Medication use restrictions
- Dose limits: For Wegovy injection requests: dose does not exceed 2.4 mg once weekly; For Wegovy tablet requests: dose does not exceed 25 mg per day
inv-02: Cardiovascular Event Prevention - Continuation Therapy
Covered when ALL of the following are met
Continuity and eligibility
- Continuity conditions: (a) For a member who has not completed 4 months of initial therapy, refer to Initial Therapy criteria; (b) For members who received compounded semaglutide, samples, or NovoCare® self-pay Wegovy, refer to Initial Therapy criteria; (c) Currently receiving medication via Centene benefit or previously met initial approval criteria; (d) Member is enrolled in a state/product with continuity of care regulations
Medication restrictions and dosing tolerance
- Injection dosing/tolerance: After initial dose escalation, member must tolerate a maintenance dose of ≥1.7 mg once weekly after at least 17 weeks of therapy; dose must not exceed 2.4 mg once weekly
- Tablet dosing/tolerance: After initial dose escalation, member must tolerate 25 mg per day; dose must not exceed 25 mg per day
inv-03: MASH - Continuation Therapy
Covered when ALL of the following are met
Duration and response
- Response criteria: (a) Improvement in fibrosis ≥1 stage from baseline with no worsening of MASH; (b) Resolution of MASH with no worsening of fibrosis; (c) No increase in fibrosis stage and no worsening of MASH from baseline
Medication restrictions and dosing
- Dose limits and tolerance: Dose must not exceed 2.4 mg once weekly; member must tolerate a maintenance dose of ≥1.7 mg once weekly after at least 17 weeks of Wegovy therapy
inv-04: Other indications / Off-label handling
Covered when ONE of the following is met
Requests for uses that are not FDA‑approved and that are not specifically addressed in this policy are excluded unless there is sufficient documentation of safety and efficacy per Health Net’s off‑label use policy CP.CPA.09 or unless coverage for the indication is established in the member’s evidence of coverage documents.
Uses that are not FDA‑approved and that are not supported by the off‑label use policy CP.CPA.09 or by evidence of coverage are considered not authorized and will be denied.
Coding and Dosing
| Ozempic® dosing | semaglutide 0.25–2 mg SC once weekly; max 2 mg/week |
| Rybelsus® dosing R1 | oral semaglutide formulation R1: max 14 mg/day |
| Rybelsus® dosing R2 | oral semaglutide formulation R2: max 9 mg/day |
| Trulicity® dosing | dulaglutide 0.75–4.5 mg SC once weekly; max 4.5 mg/week |
| Victoza® dosing | liraglutide 0.6 mg SC QD initiation; maintenance 1.2–1.8 mg/day; max 1.8 mg/day |
| Mounjaro® dosing | tirzepatide initial 2.5 mg SC once weekly to max 15 mg/week (adults) |
| Wegovy injection dosing | SC once weekly following escalation (0.25 → 0.5 → 1.0 → 1.7 → 1.7 or 2.4 mg); maximum 2.4 mg/week |
| Wegovy tablets dosing | PO following escalation (1.5 → 4 → 9 → 25 mg); maintenance 25 mg/day; maximum 25 mg/day |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required and approval is indication‑specific. Requests must meet the applicable criteria for Weight Management, Cardiovascular Event Prevention, or Metabolic Dysfunction‑Associated Steatohepatitis (MASH) as outlined in this policy (see sections A–C).
- Prior authorization required with indication‑specific criteria: Weight Management, Cardiovascular Event Prevention, or MASH
Therapeutic Alternatives Listed
Therapeutic alternatives to Wegovy (semaglutide) are available and may require prior authorization per the plan’s drug coverage rules. Examples include other GLP‑1 receptor agonists and alternative incretin‑based agents with their standard dosing limits (e.g., Ozempic®, Rybelsus®, Trulicity®, Victoza®, Mounjaro®). Refer to the dosing and maximum dose guidance in the Therapeutic Alternatives section.
- Alternatives include: Ozempic® (semaglutide) — max 2 mg/week; Rybelsus® (semaglutide) — Formulation R1 max 14 mg/day, R2 max 9 mg/day; Trulicity® (dulaglutide) — max 4.5 mg/week; Victoza® (liraglutide) — max 1.8 mg/day; Mounjaro® (tirzepatide) — max 15 mg/week (adults).
Required Documentation for Renewals and Continuation
Required documentation must be submitted with renewal and continuation requests. Provide recent clinical evidence of ongoing benefit and adherence as specified for the approved indication.
- Documentation of member's current weight within the last 30 days is required for renewals (all applicable indications).
- For Weight Management renewals: First renewal — ≥ 5% weight loss from baseline (adults) or ≥ 5% baseline BMI reduction (pediatrics). Subsequent renewals — evidence of continued weight loss or maintenance.
- For Cardiovascular Event Prevention renewals: First renewal — ≥ 5% weight loss from baseline; subsequent renewals — evidence of weight loss or maintenance; prescriber attestation that member is receiving cardiovascular standard of care (see Appendix E).
- For MASH renewals: After ≥ 12 months of therapy, objective evidence of response (e.g., ≥1‑stage fibrosis improvement with no worsening of MASH, resolution of MASH without fibrosis worsening, or no increase in fibrosis stage and no worsening of MASH).
- Documentation that member is enrolled in a Health Net–approved weight loss or lifestyle modification program and follow‑up visits are planned to assess adherence and response.
- Prescriber attestation when required (e.g., cardiovascular standard of care or standard of care for related conditions such as type 2 diabetes, dyslipidemia, hypertension).
- Confirmation that Wegovy is not prescribed concurrently with other semaglutide‑containing products or other GLP‑1 receptor agonists; for MASH, Wegovy must not be prescribed concurrently with Rezdiffra.
- Dose limits/maintenance tolerance evidence as applicable (e.g., ability to tolerate ≥1.7 mg once weekly maintenance after at least 17 weeks for certain indications; dose limits: Wegovy injection ≤2.4 mg once weekly; Wegovy tablet ≤25 mg/day).
Non‑FDA Indication Denial Rule
Requests for indications that are not FDA‑approved and not specifically addressed in this policy will be denied unless sufficient supporting documentation is provided per the Health Net off‑label use policy (CP.CPA.09) or other evidence of coverage documents.
- Non‑FDA approved indications not addressed in this policy require documentation of efficacy and safety per CP.CPA.09; otherwise, requests will be denied.
Background
Wegovy (semaglutide) is covered by Health Net for specific indications when criteria are met, including weight management, cardiovascular event prevention, and metabolic dysfunction‑associated steatohepatitis (MASH). Management expectations include enrollment in an approved lifestyle or weight‑loss program, documentation of current weight (within 30 days) for renewals, and prescriber attestations of standard‑of‑care treatment for related conditions when applicable. Continuation and renewal approvals require meeting indication‑specific response thresholds (for example, ≥5% baseline weight loss at the first renewal for adults), adherence to dosing limits (injection ≤ 2.4 mg once weekly; tablet ≤ 25 mg/day), and demonstration of tolerability to maintenance doses where specified (e.g., injection tolerance of ≥ 1.7 mg once weekly after at least 17 weeks). Prior authorization is required and evaluated against these criteria.
Definitions
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