CurrentUnitedHealthcarePolicy N/A

Wegovy (semaglutide) — Cardiovascular Risk Reduction (Pharmacy Prior Authorization)

Defines prior authorization criteria for coverage of Wegovy (semaglutide) when used specifically to reduce major adverse cardiovascular events in adults with established cardiovascular disease and overweight/obesity; applies to UnitedHealthcare pharmacy benefit adjudication.

Policy Summary

PayerUnitedHealthcare

PolicyWegovy (semaglutide) — Cardiovascular Risk Reduction (Pharmacy Prior Authorization)

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateAug 1, 2025

Next Review DateMay 1, 2025

Key ActionObtain prior authorization with documentation of established cardiovascular disease and confirm patient meets age and therapy requirements; initial approvals issued for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

≥45min patient age

≥27reauthorization BMI

Allowedweight-loss exclusion exception

Coverage Criteria for Wegovy (semaglutide) — Cardiovascular Risk Reduction

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Initial Therapy

Covered when ALL of the following are met:

Initial Authorization: 1) Treatment is requested to reduce the risk of major adverse cardiovascular events; 2) Patient is 45 years of age or older; 3) Submission of medical records documenting established cardiovascular disease evidenced by one of: prior myocardial infarction (MI); prior ischemic or hemorrhagic stroke; symptomatic peripheral arterial disease demonstrated by prior peripheral arterial revascularization, ankle-brachial index (ABI) < 0.85 at rest, or amputation due to atherosclerotic disease; 4) Wegovy is used in combination with a reduced calorie diet and increased physical activity; 5) For the relevant vascular history (MI, stroke, or symptomatic PAD), patient is on therapy from each of the specified secondary prevention classes unless there is a contraindication or intolerance (examples include a cholesterol‑lowering medication such as a statin or PCSK9 inhibitor; a beta blocker for MI history; an ACE inhibitor, ARB, or ARNI as applicable; and an antiplatelet agent such as aspirin or clopidogrel); 6) Patient does NOT have diabetes (HbA1c ≥ 6.5%) and is NOT New York Heart Association class IV heart failure.

Authorization will be issued for 12 months.

Continuation Therapy

Reauthorization covered when ALL of the following are met:

Reauthorization: 1) Body mass index (BMI) ≥ 27 kg/m^2; 2) Continued use in combination with a reduced calorie diet and increased physical activity; 3) Patient does not have New York Heart Association class IV heart failure.

Authorization periods are 12 months.

General exclusions for weight‑loss medications remain in effect; however, this policy makes a targeted exception permitting coverage of Wegovy (semaglutide) only when used for the cardiovascular (CV) risk reduction indication described in the approval criteria. Coverage is limited to treatment intended to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease who also meet the policy’s age, documentation, and concomitant‑therapy requirements. (Weight‑loss indications outside of the CV risk‑reduction pathway remain excluded.)

This CV‑indication coverage pathway specifically excludes patients with certain cardiometabolic conditions. Requests will be considered not medically necessary if the patient has diabetes with HbA1c ≥ 6.5%. Coverage is also excluded for patients with New York Heart Association (NYHA) class IV heart failure. These exclusions are denial triggers and must be confirmed on the submitted documentation.

Provider Actions, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior Authorization Required — initial approvals are for 12 months when clinical criteria are met. Submit a prior authorization request documenting the clinical criteria listed below.

Initial authorization duration: 12 months
Prior authorization required before initiation of therapy

Step Therapy

Concomitant Cardiovascular Therapy Requirement

Concomitant cardiovascular therapy requirement — patient must be on specified secondary prevention therapies unless there is a documented contraindication or intolerance. Ensure medical records show current medications from the classes listed for the patient’s qualifying cardiovascular condition.

For patients with prior myocardial infarction (MI): patient must be on therapy from each of the following classes unless contraindicated or intolerant: cholesterol‑lowering medication (e.g., statin, PCSK9), beta blocker (e.g., carvedilol, metoprolol, bisoprolol), ACE inhibitor or ARB (or ARNI), and antiplatelet therapy (e.g., aspirin, clopidogrel).
For patients with prior ischemic or hemorrhagic stroke: patient must be on therapy from each of the following classes unless contraindicated or intolerant: cholesterol‑lowering medication (e.g., statin, PCSK9), ACE inhibitor or ARB (or ARNI), and antiplatelet therapy (e.g., aspirin, clopidogrel).
For patients with symptomatic peripheral arterial disease (PAD): patient must be on therapy from each of the following classes unless contraindicated or intolerant: cholesterol‑lowering medication (e.g., statin, PCSK9), ACE inhibitor or ARB (or ARNI), and antiplatelet therapy (e.g., aspirin, clopidogrel).

Documentation Required

Required Documentation

Required documentation: submit medical records that document the patient’s age (≥ 45 years) and established cardiovascular disease with supporting evidence, and that confirm use of concomitant cardiovascular therapies or justified contraindications/intolerances.

Documentation must include evidence of established cardiovascular disease, such as: prior myocardial infarction (MI); prior ischemic or hemorrhagic stroke; symptomatic PAD evidenced by intermittent claudication with ABI < 0.85 (at rest), peripheral arterial revascularization, or amputation due to atherosclerotic disease.
Medical records must show current medication list verifying use of the required secondary prevention therapies or documentation of contraindication/intolerance to those classes.
Include treatment plan noting use in combination with reduced‑calorie diet and increased physical activity, and statement that treatment is to reduce risk of major adverse cardiovascular events.

Denial Risk

Key Denial Triggers

Key denial triggers — claims may be denied if exclusion criteria are present or required documentation is missing.

Diagnosis of diabetes with HbA1c ≥ 6.5%
New York Heart Association (NYHA) class IV heart failure
Missing documentation of established cardiovascular disease or absence of records showing required concomitant cardiovascular therapies or documented contraindications/intolerances

Initial Authorization Criteria

Initial Authorization

Initial approval criteria

Initial Authorization: Treatment is requested to reduce the risk of major adverse cardiovascular events; patient is ≥45 years of age; submission of medical records documenting established cardiovascular disease (one of: prior MI; prior ischemic or hemorrhagic stroke; symptomatic PAD evidenced by prior peripheral arterial revascularization, ABI <0.85 at rest, or amputation due to atherosclerotic disease); Wegovy used in combination with a reduced calorie diet and increased physical activity; patient is on appropriate secondary prevention cardiovascular therapies for the index vascular disease unless contraindicated or intolerant (examples: cholesterol‑lowering therapy [statin/PCSK9], beta blocker for MI history, ACE‑I/ARB/ARNI, and antiplatelet agents); absence of diabetes (HbA1c ≥6.5%) and absence of NYHA class IV heart failure.

Authorization issued for 12 months.

Policy Summary

PayerUnitedHealthcare

PolicyWegovy (semaglutide) — Cardiovascular Risk Reduction (Pharmacy Prior Authorization)

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateAug 1, 2025

Next Review DateMay 1, 2025

SourceLink

On This Page

OpenPayer

Wegovy (semaglutide) — Cardiovascular Risk Reduction (Pharmacy Prior Authorization)

Coverage Criteria for Wegovy (semaglutide) — Cardiovascular Risk Reduction

Key Clinical Thresholds and Coding-related Details

Provider Actions, Documentation, and Denial Risks

Background

Definitions

Initial Authorization Criteria

Reauthorization / Continuation Criteria

Quantity Limits and Drug-specific Notes