Wegovy (semaglutide) — Coverage for Cardiovascular Risk Reduction and MASH
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Defines prior authorization criteria for coverage of Wegovy (semaglutide) specifically for reduction of major adverse cardiovascular events in adults with established cardiovascular disease and for treatment of metabolic dysfunction‑associated steatohepatitis (MASH) with F2‑F3 fibrosis; applies to UnitedHealthcare pharmacy benefits.
Coverage for Wegovy was added for the MASH indication (metabolic dysfunction-associated steatohepatitis) with fibrosis stage F2-F3.
Authorization criteria for cardiovascular risk reduction indication specify age >=45, BMI >=27 kg/m2, documented established cardiovascular disease, absence of diabetes (A1c>6.5%) and NYHA class IV heart failure, and requirement for background secondary prevention therapies when applicable.
Coverage Criteria for Wegovy (semaglutide)
Initial Therapy — Cardiovascular Risk Reduction
Covered when ALL of the following are met:
Lists differ slightly by disease subtype per policy
Initial Therapy — MASH
Covered when ALL of the following are met:
Reauthorization Criteria — Cardiovascular and MASH
Covered when ALL of the following are met:
Authorization will be issued for 12 months
Authorization for 12 months
Authorization issued for 12 months
Medications prescribed solely for weight loss are commonly excluded from pharmacy benefits. This policy makes an exception only for Wegovy (semaglutide) when used for the two specified non–weight-loss indications: reduction of major adverse cardiovascular events in adults with established cardiovascular disease and overweight/obesity, and treatment of noncirrhotic MASH (metabolic dysfunction‑associated steatohepatitis) with fibrosis stage F2–F3. Coverage is limited to these indications and requires submission of the clinical documentation specified in the coverage criteria.
Numeric Thresholds and Coding-related Thresholds
Provider Action and Documentation Requirements
Prior authorization required for cardiovascular risk reduction and MASH
Prior authorization is required for Wegovy when requested for reduction of major adverse cardiovascular events or for treatment of metabolic dysfunction‑associated steatohepatitis (MASH); approvals are granted only when the specified clinical criteria and supporting documentation are submitted.
Possible supply limits
Supply limits may be enforced for Wegovy; the policy states limits may be in place but does not list specific quantity limits in this document.
Documentation to submit for authorization
Submit medical records documenting BMI ≥ 27 kg/m2 and evidence specific to the indication: for the cardiovascular indication, documentation of established cardiovascular disease (prior MI; prior ischemic or hemorrhagic stroke; or symptomatic PAD evidenced by ABI < 0.85, peripheral arterial revascularization, or amputation); for MASH, documentation confirming fibrosis stage F2 or F3 by VCTE (FibroScan), MRE, or liver biopsy within the past 12 months.
Denial risk: missing required documentation or unmet thresholds
Requests that lack any required documentation or do not meet numeric or clinical thresholds may be denied — common deficiencies include missing age (≥45) for the cardiovascular indication, missing BMI ≥ 27 kg/m2, absent documentation of established cardiovascular disease, failure to document absence of diabetes (A1c ≤ 6.5%), or missing confirmation of MASH fibrosis stage F2–F3.
- Age ≥ 45 years is required for the cardiovascular indication (initial authorization).
- BMI ≥ 27 kg/m2 must be documented.
- Established cardiovascular disease must be documented (prior MI, prior stroke, or symptomatic PAD with ABI < 0.85, revascularization, or amputation).
- For cardiovascular indication, provider must document absence of diabetes or HgA1c ≤ 6.5% and patient is not NYHA class IV heart failure.
- For MASH, fibrosis stage F2 or F3 must be confirmed by VCTE, MRE, or biopsy within 12 months.
Initial Authorization Requirements
Initial therapy — Initial authorization requirements summarized
Initial authorization requirements summarized:
Reauthorization / Continuation Criteria
Continuation — MASH — Reauthorization requirements for continued coverage
Reauthorization requirements for continued coverage:
12 month authorization
Continuation — Cardiovascular — Reauthorization requirements for cardiovascular indication
Reauthorization requirements for continued coverage:
12 month authorization
Step Therapy / Background Therapy Requirements
| Patient subgroup | Required background secondary prevention therapies (must be on unless contraindicated or intolerant) |
|---|---|
| History of prior myocardial infarction (MI) | Cholesterol‑lowering medication (e.g., statin, PCSK9 inhibitor); beta blocker (e.g., carvedilol, metoprolol, bisoprolol); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel) |
| History of ischemic or hemorrhagic stroke | Cholesterol‑lowering medication (e.g., statin, PCSK9 inhibitor); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel) |
| History of symptomatic peripheral arterial disease (PAD) | Cholesterol‑lowering medication (e.g., statin, PCSK9 inhibitor); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel) |
Supply and Quantity Limits
Site of Care Restrictions
No specific office/site-of-care restriction stated
No site-of-care restrictions are specified for outpatient pharmacy dispensing of Wegovy in this policy.
Background and Scope
Wegovy (semaglutide) is a GLP‑1 receptor agonist indicated in combination with a reduced calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events (cardiovascular death, non‑fatal myocardial infarction, or non‑fatal stroke) in adults with established cardiovascular disease and overweight or obesity. Wegovy is also indicated for weight management and for the treatment of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis (F2–F3). Note that while weight‑loss medications are typically excluded from coverage, this program allows coverage of Wegovy only for the cardiovascular risk‑reduction and MASH indications described above.
Definitions
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