ModifiedQualChoicePolicy AR.QC.CP.CPA.352

Semaglutide (Wegovy) coverage

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This policy defines medical necessity criteria, authorization requirements, dosing limits, and duration for coverage of semaglutide (Wegovy) for specified QualChoice commercial lines of business and select groups; it applies only to members in specified benefit plan levels (BPLs) listed in the policy.

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ModifiedQualChoicePolicy AR.QC.CP.CPA.352

Semaglutide (Wegovy) coverage

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Policy Summary

PayerQualChoice

PolicySemaglutide (Wegovy) coverage

Policy CodePolicy AR.QC.CP.CPA.352

Change TypeMaterial updates to step therapy, documentation, and program participation

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization with documentation (office notes, labs, baseline weight, and evidence of required GLP-1 trials or standard-of-care) showing the member meets indication-specific criteria.

SourceLink

POLICY UPDATE CHANGES

Removed requirement for weight-management program and updated off-label & no coverage criteria references.

Added preferred product Mounjaro to list of required trial & failure (T&F) medications.

For weight management and cardiovascular event prevention with concurrent T2DM, language changed from 'failure' to 'member has received optimal diabetic standard of care therapy as evidenced by a trial'.

Added new Wegovy HD injection 7.2 mg formulation and Wegovy tablets and prefilled syringe to policy.

12 monthscontinued therapy approval duration

16 weeksinitial approval duration (some cohorts)

6 monthsMASH approval duration

2.4 mgcommon injection maintenance dose

25 mg/daytablet maintenance dose

BPL-limitedBPL applicability

Coverage Criteria and Indications

Initial Therapy (Weight Management)

Weight Management — Wegovy is medically necessary when ALL of the following are met:

Weight Management Initial Approval: 1) Member meets one of the following: a. BMI ≥ 30 kg/m2; b. BMI ≥ 27 kg/m2 with at least one weight-related comorbidity (e.g., coronary artery/heart disease, hypertension, dyslipidemia, diabetes, elevated waist circumference); c. If age 12–17 years: BMI ≥ 95th percentile for age and sex; 2) One of the following formulation/age criteria: a. Wegovy tablet: age ≥ 18 years; b. Wegovy injection: i. members with concurrent type 2 diabetes mellitus (T2DM): age ≥ 18 years; ii. members without concurrent T2DM: age ≥ 12 years; 3) For members with concurrent T2DM: a. Member has received optimal diabetic standard of care therapy as evidenced by a trial of ≥ 3 consecutive months each of: i. Ozempic or Rybelsus; ii. Trulicity; iii. Liraglutide (Victoza); iv. Mounjaro — unless clinically significant adverse effects or contraindications; b. If switching from another GLP-1 receptor agonist, medical justification supports necessity for Wegovy (intolerance due to common class adverse effects is not acceptable justification); 4) Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 5) Documentation of member’s baseline body weight in kg is provided; 6) Request meets dosing/escalation rules: a. For Wegovy-naïve injection requests, escalation per weeks: Week 1–4: 0.25 mg weekly; Week 5–8: 0.5 mg weekly; Week 9–12: 1 mg weekly; Week 13–16: 1.7 mg weekly; (maintenance thereafter per indication); b. For Wegovy tablet requests, escalation per days: Days 1–30: 1.5 mg/day; Days 31–60: 4 mg/day; Days 61–90: 9 mg/day; Days 91 onward: 25 mg/day; c. For switches between formulations, meet the listed tolerability and maximum-dose requirements (see policy for specific conditions).see nodes

See policy text for full escalation schedules and allowable switch criteria.

Initial Therapy (Cardiovascular Event Prevention)

Cardiovascular Event Prevention — Wegovy is medically necessary when ALL of the following are met:

Cardiovascular Prevention Initial Approval: 1) Member has established cardiovascular disease (history of myocardial infarction, history of stroke, or symptomatic peripheral arterial disease); 2) Age ≥ 18 years; 3) BMI ≥ 27 kg/m2; 4) Prescriber attestation that member is currently receiving cardiovascular standard of care management; 5) For members with concurrent T2DM: a. Member has received optimal diabetic standard of care therapy as evidenced by a trial of ≥ 3 consecutive months each of Rybelsus or Ozempic, Trulicity, and Liraglutide (Victoza), unless clinically significant adverse effects or contraindications; b. If switching from another GLP-1 receptor agonist, medical justification supports necessity for Wegovy (intolerance due to common class adverse effects is not acceptable justification); 6) Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 7) Documentation of member’s baseline body weight in kg is provided; 8) Request meets dosing/escalation rules: a. For Wegovy-naïve injection requests: Week 1–4: 0.25 mg weekly; Week 5–8: 0.5 mg weekly; Week 9–12: 1 mg weekly; Week 13–16: 1.7 mg weekly; Week 17 and onward: 2.4 mg weekly; b. For Wegovy tablet requests: Days 1–30: 1.5 mg/day; Days 31–60: 4 mg/day; Days 61–90: 9 mg/day; Days 91 onward: 25 mg/day; c. For switches between formulations, meet the listed tolerability and maximum-dose requirements (see policy).see nodes

Initial approval duration noted as 16 weeks in the policy for this indication.

Initial Therapy (MASH)

Metabolic Dysfunction-Associated Steatohepatitis (MASH) — Wegovy is medically necessary when ALL of the following are met:

MASH Initial Approval: 1) Diagnosis of MASH (formerly NASH); 2) Prescribed by or in consultation with a hepatologist or gastroenterologist; 3) Age ≥ 18 years; 4) MASH with stage F2–F3 fibrosis confirmed by either: a. Liver biopsy within the last 3 years; or b. Both a serum-based assessment and an imaging-based assessment within the last 6 months (examples in Appendix G); 5) For members with concurrent T2DM: member has received optimal diabetic standard of care therapy as evidenced by a trial of ≥ 3 consecutive months each of Ozempic or Rybelsus, Trulicity, Mounjaro, and Liraglutide (Victoza), unless clinically significant adverse effects or contraindications; 6) Prescriber attestation that member is receiving standard of care management for related conditions (T2DM, dyslipidemia, hypertension); 7) Wegovy is not prescribed concurrently with Rezdiffra; 8) Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 9) Dosing follows escalation schedule with maintenance up to 2.4 mg once weekly per policy dosing table.see nodes

Approval duration for MASH is 6 months.

Initial Therapy — Initial therapy criteria differ by indication

Initial therapy criteria differ by indication and all criteria for the requested indication must be met.

Indication-specific initial therapy: Initial therapy requirements are indication specific (Weight Management, Cardiovascular prevention, MASH). The requester must meet every criterion listed for the selected indication, including BMI/age thresholds, prescriber qualifications (for MASH), prior diabetic therapy trials when applicable, baseline weight documentation, and adherence to dosing escalation and maximum doses for the chosen formulation.

Wegovy (semaglutide) is an excluded benefit for all groups except members enrolled in benefit plan levels 2JX62130, 2JX62131, 2JX42002, and 2JX42003. Requests for members outside these BPLs should be treated as non-covered per plan eligibility rules.

Use of Wegovy for non‑FDA–approved indications not specifically addressed in this policy is excluded unless the provider submits sufficient documentation of efficacy and safety per the off‑label use policy (CP.CPA.09) or applicable evidence of coverage documents to support authorization.

Inclusion or exclusion of any billing or procedure codes in this policy does not guarantee coverage. Providers must follow the plan's coverage determinations and current professional coding guidance when submitting claims; coding alone is not authorization for payment.

Coadministration of Wegovy with other semaglutide‑containing products or with any other GLP‑1 receptor agonist is not recommended and is disallowed by this policy. For MASH specifically, Wegovy must not be prescribed concurrently with Rezdiffra™. Concurrent prescriptions are a basis for denial.

Requests for Wegovy to treat non‑FDA–approved indications without sufficient supporting documentation per the off‑label use policy are considered not authorized and may be denied.

Initiation Requirements

Initial therapy — Initiation requires dose escalation per product labeling

Initiation requires dose escalation per product labeling; escalation dosages are not approved as maintenance.

Dose escalation required: Initiation must follow the product-specific escalation schedule. Injection escalation examples: Week 1–4: 0.25 mg weekly; Week 5–8: 0.5 mg; Week 9–12: 1 mg; Week 13–16: 1.7 mg; maintenance doses are 1.7 mg or 2.4 mg (0.25, 0.5, 1 mg are initiation/escalation only and not approved as maintenance). For patients who tolerate 2.4 mg weekly for ≥4 weeks and require additional weight reduction, dose may be increased up to 7.2 mg once weekly per policy. Tablet escalation examples: Days 1–30: 1.5 mg/day; Days 31–60: 4 mg/day; Days 61–90: 9 mg/day; Days 91 onward: 25 mg/day (25 mg is recommended maintenance; if not tolerated consider switching to injection).

Initial therapy / step requirements — Policy history and criteria updates

Policy history and step/requirement updates relevant to initiation:

Step therapy / formulary redirection: Policy history records addition of preferred product Mounjaro to the list of required trial & failure (T&F) medications and updates that may redirect to formulary alternative GLP-1 agonists before semaglutide in some pathways.

Continuation and Renewal Criteria

Continued Therapy / Renewal

Continued Therapy — continued coverage is authorized when ALL of the following are met:

Continued Therapy Criteria: 1) Member is currently receiving medication via Centene benefit or previously met initial approval criteria; 2) Member is responding positively to therapy: a. If first renewal, adult members have lost ≥ 5% of baseline body weight (pediatrics: ≥5% of baseline BMI); b. For second or subsequent renewals, member has lost weight and/or maintained weight loss (adults) or achieved/reduced and/or maintained BMI (pediatrics); 3) Documentation of member’s current body weight in kg; 4) Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 5) Request meets dosing/tolerance rules: a. For injection: requested dose ≤ 2.4 mg weekly and after escalation member tolerates maintenance dose ≥ 1.7 mg weekly; OR requested dose > 2.4 mg weekly only if member tolerated 2.4 mg weekly for ≥ 4 weeks and dose does not exceed 7.2 mg weekly; b. For tablet: member tolerates maintenance dose of 25 mg/day, dose does not exceed 25 mg/day, and dose does not exceed 1 tablet/day; 6) Approval duration for continued therapy varies by indication (commonly 12 months per policy).see nodes

Clinical response requirements differ for first vs subsequent renewals.

Cardiovascular Event Prevention — Renewal Criteria

Cardiovascular Event Prevention — Renewal Criteria — Covered when ALL of the following are met:

Step Therapy and Prior Trials

Requirement	Detail
Required step therapy for members with concurrent T2DM
Member must have received optimal diabetic standard-of-care therapy as evidenced by a trial of ≥3 consecutive months each of: Ozempic® or Rybelsus®, Trulicity®, Liraglutide (Victoza®), and Mounjaro, unless clinically significant adverse effects are experienced or all are contraindicated; prior authorization may be required.
If member is currently receiving a GLP-1 receptor agonist and requests switching to Wegovy, medical justification must support the necessity for Wegovy; intolerance due to common GLP-1 class adverse effects (e.g., gastrointestinal symptoms) is not acceptable justification.

Requirement	Detail
Tolerability of escalation dosing
After the initial dose escalation period, member must be able to tolerate a maintenance injection dose of ≥1.7 mg once weekly prior to approval of higher maintenance doses (requested dose ≤2.4 mg/week requires tolerance ≥1.7 mg after escalation).
For requested doses >2.4 mg once weekly, member must have tolerated 2.4 mg once weekly for at least 4 weeks and the dose must not exceed 7.2 mg once weekly.
If patients do not tolerate a dose during escalation, consider delaying escalation for 4 weeks; escalation dosages (0.25, 0.5, 1 mg) are initiation doses and are not approved as maintenance.

Requirement	Detail
Formulary redirection / preferred agent trial
Policy history includes redirections to formulary alternative GLP‑1 agonists and addition of preferred product Mounjaro to the list of required trial & failure (T&F) medications; trial of preferred formulary agents may be required prior to semaglutide coverage.
For members with concurrent T2DM, trials of other GLP‑1 agents (see step therapy) and any formulary-preferred agents must be documented unless contraindicated; prior authorization may be required for those agents.

Coding and Dose Summary

Referenced HCPCS CodesHCPCS

C9399	Unclassified drugs or biologicals
J3490	Unclassified drugs

BMI criteria

Adult BMI (primary)BMI ≥ 30 kg/m2

Adult BMI with comorbidityBMI ≥ 27 kg/m2 with at least one weight‑related comorbidity (e.g., coronary artery disease, hypertension, dyslipidemia, diabetes)

Pediatric BMI (ages 12–17)BMI ≥ 95th percentile for age and sex (see Appendix D)

Maximum dose (injection)

Maximum injection dose (policy)7.2 mg once weekly (maximum allowed if patient tolerated 2.4 mg weekly for ≥4 weeks and additional weight reduction is clinically indicated)

Common maintenance ceiling (many scenarios)2.4 mg once weekly (recommended maintenance in many indications)

Formulation Limits and Administration

Wegovy injection — dosing overview

Standard maintenance dosingCommon maintenance dosing is 2.4 mg once weekly for many indications

Escalation schedule and maintenance capsInjection dosing must follow labeled escalation schedule (0.25 → 0.5 → 1 → 1.7 → maintenance) and meet maintenance tolerance rules before higher doses are approved

High‑dose formulation allowancePolicy allows escalation beyond 2.4 mg up to a maximum of 7.2 mg once weekly when criteria are met (patient tolerated 2.4 mg for ≥4 weeks and additional weight reduction is indicated)

Wegovy tablet — titration & maintenance

Titration to maintenanceOral Wegovy titration: Days 1–30: 1.5 mg; Days 31–60: 4 mg; Days 61–90: 9 mg; Days 91 onward: 25 mg

Maintenance dose

Provider Requirements and Documentation

Prior Authorization

Obtain prior authorization and document eligibility

Prior authorization is required. The provider must document that the member meets the specific initial or continuation criteria including BMI/age eligibility, indication-specific requirements, prior diabetes therapy trials when applicable, dosing limits, and baseline body weight (kg).

Document baseline body weight in kg
Confirm BMI or CVD/MASH indication-specific criteria are met
Include evidence of prior GLP‑1 trials for members with T2DM when required

Prior Authorization

Approvals issued for 12 months — meet renewal criteria

Prior authorization approvals are issued for up to 12 months. Providers must ensure requests meet the indication‑specific continuation/renewal criteria (see cardiovascular prevention and MASH renewal rules) to receive a 12‑month approval.

Ensure renewal shows required clinical response (e.g., ≥5% weight loss at first CV renewal)

Definitions and Trial References

Wegovy (semaglutide)

Active ingredient and classWegovy: semaglutide, a glucagon‑like peptide‑1 (GLP‑1) receptor agonist

Indication summaryIndicated for weight reduction/maintenance in adults and pediatric patients ≥12 with obesity, cardiovascular event risk reduction in adults with established CVD and overweight/obesity, and treatment of noncirrhotic MASH (F2–F3) in adults

Coadministration limitationCoadministration with other semaglutide‑containing products or with any other GLP‑1 receptor agonist is not recommended per labeling

BMI

DefinitionBody mass index (BMI)

Calculation (Appendix D)BMI = 703 × [weight (lbs) / height (inches)^2]

Clinical Background

Semaglutide (Wegovy) is a glucagon‑like peptide‑1 (GLP‑1) receptor agonist indicated for: (1) reduction of major cardiovascular events in adults with established cardiovascular disease who have overweight or obesity; (2) long‑term weight reduction and maintenance in adults and pediatric patients aged ≥12 years with obesity (and adults with overweight plus at least one weight‑related comorbidity); and (3) treatment of noncirrhotic metabolic dysfunction‑associated steatohepatitis (MASH) with stage F2–F3 fibrosis in adults. Coadministration with other semaglutide products or other GLP‑1 receptor agonists is not recommended.

Administration and Site of Care

Note

Administer per dosing route: SC injections weekly; tablets once daily

Subcutaneous injections should be administered per the product dosing escalation and maintenance schedule; oral tablets are administered once daily per the tablet escalation schedule.

Follow the labeled SC weekly escalation schedule for injections
For tablets, follow the daily escalation to maintenance (25 mg/day)

Policy Revision History

2025-10-14step_therapy_update

Added preferred product Mounjaro to the list of required trial-and-failure (T&F) medications and updated redirections to formulary alternative GLP-1 agonists for weight management, MASH, and cardiovascular event protection with concurrent T2DM.

2025-11-12regulatory_alignment

Updated policy based on new FDA approval of Rybelsus for MACE risk, with related step-therapy and formulary language adjustments.

2025-10-14continuation_clarification

Policy Summary

PayerQualChoice

PolicySemaglutide (Wegovy) coverage

Policy CodePolicy AR.QC.CP.CPA.352

Change TypeMaterial updates to step therapy, documentation, and program participation

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

CV prevention renewal: 1) Member is currently receiving medication via Centene benefit or previously met initial approval criteria; 2) Member is responding positively to therapy as evidenced by: a. If first renewal, member has lost ≥ 5% of baseline body weight; b. If second or subsequent renewal, member has lost weight and/or maintained weight loss on therapy; 3) Documentation of current body weight in kg; 4) Prescriber attestation of receiving cardiovascular standard of care management; 5) Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 6) Request meets dosing/tolerance rules for injection or tablet: a. Injection — either i. requested dose ≤ 2.4 mg once weekly AND after escalation member tolerates maintenance dose ≥ 1.7 mg once weekly; OR ii. requested dose > 2.4 mg once weekly AND both: member tolerated 2.4 mg once weekly for ≥ 4 weeks AND dose does not exceed 7.2 mg once weekly; b. Tablet — after escalation member tolerates maintenance dose of 25 mg/day AND dose does not exceed 25 mg/day AND does not exceed 1 tablet/day.

Approvals for continuation in this indication are commonly issued for 12 months.

Metabolic Dysfunction-Associated Steatohepatitis (MASH) — Renewal Criteria

Metabolic Dysfunction-Associated Steatohepatitis (MASH) — Renewal Criteria — Covered when ALL of the following are met:

MASH continuation: 1) Member is currently receiving medication via Centene benefit or previously met initial approval criteria; 2) After at least 12 months of therapy, member is responding positively as evidenced by at least one of: 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; 3) Prescriber attestation that member is receiving standard of care management for concomitant related conditions (T2DM, dyslipidemia, hypertension);

Approval duration for MASH continuation documented as 12 months in policy tables.

Continuation Therapy — Continuation criteria for Wegovy (weight management and CVD)

Continuation criteria for Wegovy (weight management and CVD):

Continuation — general rules: Member must be currently receiving medication via the benefit or have previously met initial approval criteria; demonstrate clinical response per indication (≥5% weight loss at first renewal for adults or specified fibrosis/MASH improvements for MASH); provide documentation of current weight; not be prescribed Wegovy concurrently with other semaglutide-containing products or other GLP-1 receptor agonists; and meet dosing/tolerance rules (injection and tablet) described in the policy before renewal is authorized.

Continuation therapy — Continuation/renewal requires evidence of clinical response and prescriber attestation of ongoing standard of care

Continuation/renewal requires evidence of clinical response and prescriber attestation of ongoing standard of care.

Prescriber attestation and evidence: At renewal, prescriber must attest that the member is receiving ongoing standard of care management appropriate to the indication (cardiovascular standard of care for CVD prevention; standard of care for comorbid conditions in MASH) and submit documentation of clinical response (weight loss metrics or fibrosis/MASH assessments as applicable).

Continuation therapy clarifications

Policy history clarifications regarding continued therapy:

Continuation clarifications: Policy history notes revisions: added preferred product Mounjaro to required T&F lists; revised language for members with concurrent T2DM from 'failure' to 'member has received optimal diabetic standard of care therapy as evidenced by a trial'; and clarified criteria for second or subsequent renewals for adults and pediatric patients regarding BMI reduction and/or maintenance on therapy.

Escalation doses not maintenance0.25, 0.5, and 1 mg once-weekly dosages are initiation/escalation doses and are not approved as maintenance doses

Tablet maintenance dose

Recommended tablet maintenance dose25 mg per day (oral Wegovy)

Tablet titration scheduleDays 1–30: 1.5 mg; Days 31–60: 4 mg; Days 61–90: 9 mg; Days 91 onward: 25 mg

Tablet dosing capLimit 1 tablet per day

The presence or absence of specific codes in this policy is informational only; code lists do not guarantee coverage. Claims may be denied if coding or documentation do not meet plan requirements, so providers should verify coding and coverage rules before billing.

Recommended maintenance oral dose is 25 mg once daily

Tablet daily limitLimit 1 tablet per day; if 25 mg not tolerated consider switching to injection 1.7 mg once weekly

Wegovy injection — maximum

Policy maximum injection dose7.2 mg once weekly (maximum per policy when escalation criteria met)

Intermediate requirementPatient must have tolerated 2.4 mg once weekly for at least 4 weeks before increases above 2.4 mg are allowed

Escalation not maintenanceInitiation/escalation doses (0.25, 0.5, 1 mg) are not approved as maintenance doses

Wegovy tablets — maximum

Policy maximum tablet dose25 mg per day

Tablet quantity limitDose does not exceed 1 tablet per day

Tolerance requirementAfter escalation, member must tolerate 25 mg per day to remain on tablet maintenance; if not tolerated consider switching to injection

For MASH, provide evidence after ≥12 months as specified (fibrosis improvement, resolution, or no worsening)

Billing Rule

Use HCPCS C9399 / J3490 with supporting documentation

When billing unclassified drug codes, reference HCPCS C9399 or J3490 per policy. Prior authorization requirements and clinical criteria in this policy apply regardless of use of these unclassified codes.

Include supporting clinical documentation when submitting C9399 or J3490
Remember inclusion of codes in the policy does not guarantee coverage

Step Therapy

Document required GLP‑1 trials for members with T2DM

For members with concurrent type 2 diabetes mellitus, document trials of other GLP‑1 receptor agonists (Ozempic/Rybelsus, Trulicity, Liraglutide/Victoza, and Mounjaro) of ≥3 consecutive months each unless contraindicated.

Specify duration (≥3 months) for each agent trialed
If switching from a GLP‑1, provide medical justification (class intolerance due to common GI effects is not acceptable)

Prior Authorization

Attest to CV standard of care and show initial treatment response

For cardiovascular event prevention indications, the provider must attest that the member is receiving cardiovascular standard‑of‑care management and demonstrate an initial positive response (first renewal: ≥5% baseline weight loss); dosing and tolerance rules (maintenance tolerance ≥1.7 mg weekly; higher doses require prior tolerance of 2.4 mg for ≥4 weeks) must be met.

Prescriber attestation of cardiovascular standard of care (Appendix E)
Provide weight change data demonstrating required response at renewal
Ensure dose request meets tolerance rules before requesting >2.4 mg weekly

Step Therapy

Follow step therapy / formulary redirections (preferred agent trials)

Policy history requires trial of preferred formulary agents (e.g., Mounjaro) and redirection to formulary alternatives per step therapy before semaglutide may be authorized in some pathways; providers should follow formulary‑directed trial requirements.

Confirm whether trial of preferred agent (Mounjaro) is required per member's formulary
Document trials and outcomes of formulary alternatives when applicable

Documentation Required

Submit office chart notes and labs with authorization request

Provider must submit office chart notes, lab results, and other clinical information demonstrating the member meets all approval criteria, including baseline body weight and evidence of prior therapy where required.

Include baseline and current body weight in kg in documentation
Attach lab results and relevant office visit notes showing indication and prior treatments

Documentation Required

Include current weight and prescriber attestation of standard‑of‑care

Documentation must include current body weight (kg) and prescriber attestation that the member is receiving appropriate standard‑of‑care management for cardiovascular risk or related conditions; include evidence of positive response to therapy as defined per indication.

Provide prescriber attestation of cardiovascular or MASH standard‑of‑care management
Document measured current body weight in kg at renewal

Documentation Required

Document optimal diabetic standard‑of‑care trials for members with T2DM

For members with concurrent T2DM receiving Wegovy for weight management or CV prevention, document that the member has received optimal diabetic standard‑of‑care therapy as evidenced by trials of the listed GLP‑1 agents (policy language revised to require evidence of a trial rather than 'failure').

Show trials of Rybelsus/Ozempic, Trulicity, Liraglutide, and Mounjaro where required
If trials were not completed, document clinical contraindication or adverse effects

Denial Risk

Incomplete documentation may trigger denial

Failure to submit required documentation (office notes, labs, or other clinical information) that supports the member met approval criteria may result in denial of the authorization request.

Ensure all requested clinical information is provided with the PA submission to avoid delays or denials

Denial Risk

Non‑FDA indications require off‑label documentation

Requests for non‑FDA‑approved indications not addressed by this policy are excluded and may be denied unless sufficient evidence is provided per the off‑label use policy (CP.CPA.09).

If requesting off‑label use, attach evidence of efficacy and safety consistent with off‑label policy requirements

Denial Risk

Do not co‑prescribe Wegovy with other semaglutide/GLP‑1 products

Wegovy must not be prescribed concurrently with other semaglutide‑containing products, Rezdiffra, or any other GLP‑1 receptor agonist(s); concurrent prescriptions are a basis for denial.

Verify there is no overlapping semaglutide or other GLP‑1 agent on the medication list before submitting the request

Billing Rule

Coding inclusion does not guarantee coverage — verify coding and documentation

Inclusion of HCPCS or other codes in this policy does not guarantee coverage. Claims may be denied if coding or documentation do not meet plan requirements; providers should follow current professional coding guidance and plan procedures.

Reference most up‑to‑date coding guidance when submitting claims
Provide clinical documentation to support coding claims

Use in policyBMI thresholds used for adult and pediatric coverage criteria (see policy BMI cut‑offs)

Symptomatic PAD (SELECT trial definition)

SELECT trial symptomatic PAD definitionIntermittent claudication with ankle‑brachial index (ABI) < 0.85 at rest, or peripheral arterial revascularization, or amputation due to atherosclerotic disease

ContextUsed to define symptomatic PAD for cardiovascular event prevention eligibility

SourceAppendix E (SELECT trial definitions) in policy

SELECT trial

Trial name and purposeSELECT — a cardiovascular outcomes trial evaluating semaglutide for heart disease and stroke prevention in patients with overweight or obesity

Relevance to policySELECT provides definitions and evidence supporting cardiovascular event prevention indication and criteria

ReferencesClinicalTrials.gov and NEJM/related publications listed in policy references

Revised continued therapy language for members with concurrent T2DM from 'failure' to 'member has received optimal diabetic standard of care therapy as evidenced by a trial' to align with MASH criterion.

2026-06-19formulation_and_continuation_updateLatest

Clarified continuation criteria for second or subsequent renewals (age-specific BMI reduction/maintenance requirements) and added the Wegovy HD 7.2 mg injection formulation; references were reviewed and updated.

2025-02-27operational_adaptationLatest

Policy reviewed and adapted for AR QualChoice-specific use; removed the requirement for participation in a weight-management program and updated off-label and no-coverage policy references.