ModifiedmhnPolicy HNCA.CP.CPA.352

Semaglutide (Wegovy)

Defines coverage criteria, dosing, contraindications, and administrative requirements for Wegovy (semaglutide) for weight management, cardiovascular event prevention, and MASH for members covered by the payer.

Policy Summary

Payermhn

PolicySemaglutide (Wegovy)

Policy CodePolicy HNCA.CP.CPA.352

Change TypeMultiple operational and clinical updates (formulation addedMASH criteriaprogram and continuity clarifications)

Effective DateSep 24, 2021

Next Review Date

Key ActionSubmit prior authorization with indication-specific documentation including recent weight, prescriber attestation of enrollment in a 6‑month weight loss program, and dosing/titration history.

SourceLink

POLICY UPDATE CHANGES

Wegovy tablets (oral formulation) were added to the policy.

Criteria updated for FDA-approved MASH indication with biopsy lookback changes and imaging biomarker updates.

Added requirement for documentation of enrollment in a weight loss program for at least 6 months prior to GLP-1 use.

Continuation criteria and dosing exceptions updated including allowance for switching from Zepbound to Wegovy and changes to gap/grace period from 60 to 90 days.

Compounded medications and samples exclusion added.

3covered indications

2.4 mg/wkmax injection dose

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Coverage Criteria for Wegovy (semaglutide)

Continuation Therapy — Weight Management

Weight management — continuation requirements (excerpt):

Weight management continuation

Injection dosing (one of): For Wegovy injection requests, one of the following: (i) after the initial dose escalation period, member is able to tolerate a maintenance dose of ≥ 1.7 mg once weekly after at least 17 weeks of Wegovy therapy; OR (ii) dose does not exceed 2.4 mg once weekly.
Tablet dosing (one of): For Wegovy tablet requests, one of the following: (i) after the initial dose escalation period, member is able to tolerate a maintenance dose of 25 mg per day; OR (ii) dose does not exceed 25 mg per day.

Program enrollment and documentation: Member is actively enrolled in a Health Net approved weight loss program or other prescriber-recommended lifestyle modification plan that involves reduced calorie diet, increased physical activity, and behavioral modification; documentation of current weight is provided as required.

Continuation Therapy — Cardiovascular Event Prevention

Cardiovascular event prevention (must meet all):

Cardiovascular event prevention continuity

Response to therapy (one of): If first renewal: member has lost ≥ 5% of baseline body weight; If second or subsequent renewal: member has lost weight and/or maintained weight loss on therapy.
Injection dosing (both conditions apply): For Wegovy injection requests: after the initial dose escalation period, member is able to tolerate a maintenance dose of ≥ 1.7 mg once weekly after at least 17 weeks of Wegovy therapy; (and) dose does not exceed 2.4 mg once weekly.
Tablet dosing (one of): For Wegovy tablet requests: after the initial dose escalation period, member is able to tolerate a maintenance dose of 25 mg per day; OR dose does not exceed 25 mg per day.

Continuation Therapy — MASH

Metabolic Dysfunction‑Associated Steatohepatitis (MASH) (must meet all):

MASH therapy continuation

Dosing: Dose does not exceed 2.4 mg once weekly; member is able to tolerate a maintenance dose of ≥ 1.7 mg once weekly after at least 17 weeks of Wegovy therapy.

Compounded/samples routing: For members who received compounded semaglutide products, samples, or NovoCare® self-pay Wegovy, refer to Initial Therapy criteria for routing.

Other Indications / Off‑label routing

Other diagnoses/indications and exclusions:

Administrative routing for recent label changes: If the drug has undergone a label change within the last 6 months that is not yet reflected in this policy, route to the formulary/no-coverage policy CP.CPA.190 as applicable (formulary vs non-formulary).see referenced policies

Use policy CP.CPA.190 for recent label changes

Off-label requests: If the requested use is not specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND the recent-label-change routing does not apply, refer to the off-label use policy CP.CPA.09 for consideration; non‑FDA approved indications not addressed in this policy will be denied unless sufficient documentation per CP.CPA.09 is provided.see CP.CPA.09

Administrative routing for novel indications

Coverage criteria highlights

Policy covers semaglutide (Wegovy) when program, dosing, and diagnostic criteria per indication are met. Key criteria updates are:

Weight loss program requirement: Member has been actively enrolled in a weight loss program involving behavioral modification for at least 6 months prior to GLP-1 use.6 months

Program may be Health Net approved or recommended by prescriber

Formulations: Wegovy is available as prefilled pens (0.25–2.4 mg) and tablets (1.5, 4, 9, 25 mg); oral formulation (tablets) has been added to the policy.

Operational for dosing and prior authorization

Maintenance dosing: Per updated prescribing information, maintenance dose must be ≥ 1.7 mg once weekly (with specified dosing/titration exceptions for certain switches).>= 1.7 mg once weekly

Requests for uses that are non‑FDA approved indications and are not specifically addressed in this policy will be excluded unless the request includes sufficient documentation of efficacy and safety per the payer's off‑label use policy (CP.CPA.09) or other applicable evidence of coverage documents.

Semaglutide (Wegovy) is contraindicated in persons with a personal or family history of medullary thyroid carcinoma (MTC) or with multiple endocrine neoplasia syndrome type 2 (MEN 2). Additionally, therapy is contraindicated in individuals with a known hypersensitivity reaction to semaglutide or any excipients in Wegovy. The policy also notes the manufacturer boxed warning regarding the risk of thyroid C‑cell tumors.

Compounded semaglutide products and medication samples are excluded from coverage. Members who previously received compounded semaglutide or NovoCare® self‑pay Wegovy may be redirected to initial therapy criteria and should follow the requirements for initial approval rather than automatic continuation.

For continuity and renewal considerations, requests that involve prior receipt of compounded product or samples must be adjudicated per the policy's redirection to initial criteria language and documentation requirements.

Concurrent use of Wegovy with any other semaglutide‑containing product or with any other GLP‑1 receptor agonist is not permitted and will be considered not medically necessary. For the MASH indication, Wegovy must not be prescribed concurrently with Rezdiffra.

Coding and Dosing Thresholds

HCPCS codes referenced (informational)HCPCS

C9399	Unclassified drugs or biologicals
J3490	Unclassified drugs

Weight loss for first renewal (CV prevention)

First renewal weight-loss threshold (CV prevention)Member must have lost ≥ 5% of baseline body weight at first renewal.

Documentation timingCurrent weight must be documented within the last 30 days.

Program enrollmentMember must be actively enrolled in a Health Net–approved weight loss program or other prescriber‑recommended lifestyle modification plan involving diet, activity, and behavioral modification.

Concurrent therapy exclusionWegovy must not be prescribed concurrently with other semaglutide-containing products or any other GLP‑1 receptor agonist(s).

Dosing requirement for renewalFor injection: member must tolerate a maintenance dose ≥ 1.7 mg once weekly after at least 17 weeks of therapy (and dose ≤ 2.4 mg/week). For tablets: member must tolerate 25 mg/day and dose ≤ 25 mg/day.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests will be reviewed against indication-specific criteria (weight management, cardiovascular event prevention, or MASH). Initial and continuation requirements differ by indication and formulation (injection vs tablet). Members who received compounded semaglutide, samples, or NovoCare® self-pay Wegovy are redirected to initial therapy criteria. Continuation may be redirected to initial criteria if the member has not completed the required initial therapy duration for the indication.

Prior authorization required for all Wegovy (semaglutide) requests.
Indication-specific criteria apply: Weight Management, Cardiovascular Event Prevention (CVE), and Metabolic Dysfunction‑Associated Steatohepatitis (MASH).
Members who received compounded semaglutide, samples, or NovoCare® self-pay Wegovy must meet Initial Therapy criteria.

Denial Risk

Compounded Medications and Samples Exclusion

Compounded products and samples are excluded from continuation/redirected approvals; requests involving compounded semaglutide or samples are evaluated using Initial Therapy criteria. Redirects to initial criteria are required when prior therapy involved compounded medication, samples, or NovoCare® self-pay Wegovy.

Background

Semaglutide (Wegovy) is approved for weight management, cardiovascular event prevention, and metabolic dysfunction‑associated steatohepatitis (MASH). Dosing and continuation requirements differ by indication: for injections the policy requires tolerance of a maintenance dose of ≥ 1.7 mg once weekly after at least 17 weeks or that the dose does not exceed 2.4 mg once weekly; for tablets the policy requires tolerance of 25 mg per day or that the dose does not exceed 25 mg per day. For MASH, approval is contingent on injection formulation use and demonstration of response after at least 12 months of therapy (examples include improvement in fibrosis ≥1 stage with no worsening of MASH, resolution of MASH with no worsening of fibrosis, or no increase in fibrosis stage and no worsening of MASH).

Definitions and BMI Thresholds

Definition of MASH

Core definition of MASHMetabolic dysfunction‑associated steatohepatitis (MASH) is defined by the presence of ≥ 5% hepatic steatosis with inflammation and hepatocyte injury (hepatocyte ballooning), with or without fibrosis.

Related nomenclatureMASH replaced prior terms NASH/NAFLD per international consensus; MASLD refers to metabolic dysfunction‑associated steatotic liver disease.

Assessment examplesExamples of combined serum and imaging‑based tests for MASH include FAST, MAST, and MEFIB scores (e.g., FibroScan+AST, MRI‑based scores+MRE+AST, FIB‑4+MRE).

WHO BMI categories and pediatric BMI percentile thresholds

WHO adult BMI categoriesUnderweight: <18.5 kg/m²; Normal: 18.5–24.9 kg/m²; Overweight: 25.0–29.9 kg/m²; Obese ≥30 kg/m² (Class I: 30.0–34.9; Class II: 35.0–39.9; Class III: ≥40).

Pediatric threshold reference

Policy Summary

Payermhn

PolicySemaglutide (Wegovy)

Policy CodePolicy HNCA.CP.CPA.352

Change TypeMultiple operational and clinical updates (formulation addedMASH criteriaprogram and continuity clarifications)

Effective DateSep 24, 2021

Next Review Date

SourceLink

On This Page

Injection maintenance thresholdAfter escalation, member must tolerate a maintenance dose of ≥ 1.7 mg once weekly (after at least 17 weeks); maximum 2.4 mg/week.

Tablet maintenance thresholdRecommended maintenance dosage for Wegovy tablets is 25 mg daily; if not tolerated, consider switching to Wegovy injection 1.7 mg once weekly; maximum 25 mg/day.

Escalation tolerability guidanceIf patients do not tolerate a dose during escalation, consider delaying dose escalation for 4 weeks (injection) or adjusting per tablet guidance.

Maintenance dose (per updated PI)

Required maintenance dose per updated PIPer updated prescribing information, maintenance dose must be ≥ 1.7 mg once weekly for Wegovy injection (recommended maintenance 2.4 mg or 1.7 mg; maintenance must be ≥1.7 mg).

Pediatric maintenance noteDosing regimens updated to include pediatric patients aged ≥ 12 years following the escalation schedule with maintenance at 1.7 mg or 2.4 mg as indicated.

Operational clarificationPolicy was revised to require and allow ≥ 1.7 mg once weekly maintenance dose per PI update (PA decisions must reflect this requirement).

Documentation Required

Required Documentation for Renewals

Documentation required for renewal/continuation requests includes objective weight measures, program enrollment evidence, and prescriber attestations of standard-of-care management where applicable.

Current body weight documented within the last 30 days (kg preferred).
Baseline body weight (kg) for initial and current weight for continuations as applicable.
Prescriber attestation of enrollment in a provider-directed weight loss program or Health Net approved program and that the member continues the recommended reduced calorie diet, increased physical activity, and behavioral modification adjunct to therapy.
For CVE indication: prescriber attestation that member is receiving cardiovascular standard-of-care management (see Appendix E).
For MASH continuation: objective evidence of improvement after ≥ 12 months of therapy (see MASH-specific documentation callout).

Documentation Required

MASH Response Documentation (Continuation)

For requests related to MASH continuation, include objective documentation demonstrating improvement after at least 12 months of therapy (e.g., biopsy or accepted non-invasive biomarker evidence).

After ≥ 12 months of therapy, documentation must show improvement such as ≥1-stage fibrosis improvement without worsening MASH, resolution of MASH without fibrosis worsening, or no increase in fibrosis stage and no worsening of MASH from baseline.
Acceptable documentation options: liver biopsy within the lookback period or accepted non-invasive imaging/biomarker testing (e.g., VCTE with validated thresholds, MAST/FAST/MEFIB as specified in Appendix F).
If member previously received compounded product/samples, redirect to Initial Therapy criteria.

Documentation Required

Weight Loss Program and Weight Documentation

Documentation of participation in a weight loss program is required for initial and continued approvals. The program must involve behavioral modification and the member must have been actively enrolled for at least 6 months where specified.

Member must be actively enrolled in a Health Net approved weight loss program (e.g., Weight Watchers, Active&Fit) or another provider-recommended lifestyle modification plan involving a reduced calorie diet, increased physical activity, and behavioral modification.
Policy update requires documentation that the member has been actively enrolled in the weight loss program for at least 6 months for the applicable criteria.
For renewals, confirm ongoing enrollment and provide current weight within 30 days.

Step Therapy

Preferred GLP-1 Trial for Members with Concurrent T2DM

When the member has concurrent type 2 diabetes (T2DM), a trial of preferred GLP-1 agents is required prior to Wegovy in certain indications unless exceptions apply.

Preferred GLP-1 trial options include Rybelsus (oral semaglutide), Ozempic (semaglutide), Trulicity (dulaglutide), and Victoza (liraglutide) per Appendix G therapeutic alternatives.
Documentation must show member has received optimal diabetic standard-of-care therapy as evidenced by a trial of the preferred agents (Rybelsus, Trulicity, and Liraglutide) when required by the indication (e.g., MASH and certain weight/CVE scenarios).
If member is currently receiving a GLP-1 receptor agonist under the Centene benefit and meets other continuation criteria, provide medical necessity documentation per policy.

Weight-loss plateau definition for dose titration exceptions

Definition of weight‑loss plateauWeight‑loss plateau is defined in the policy (added to initial criteria and Appendix D) to support dose titration exceptions when switching from Zepbound to Wegovy due to insufficient further weight loss.

Use for titration exceptionsBMI and dose titration exceptions may be allowed for members switching from Zepbound to Wegovy if a weight‑loss plateau is documented per the policy's definition.

Operational contextDefinition was added alongside removal of name/start date requirements for weight‑loss programs and to clarify dose titration during switching scenarios.