Wegovy (semaglutide) — Prior Authorization for Cardiovascular Risk Reduction and MASH
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Defines prior authorization criteria for coverage of Wegovy (semaglutide) injection and tablets for reduction of major adverse cardiovascular events in adults with established cardiovascular disease plus overweight/obesity, and for Wegovy injection for treatment of metabolic dysfunction-associated steatohepatitis (MASH). Affects UnitedHealthcare members subject to pharmacy clinical programs.
Coverage for Wegovy tablets was added and indications were differentiated by formulation.
Coverage for Wegovy injection was added for MASH indication.
BMI requirement was removed from CVD reauthorization criteria.
Coverage Criteria
Initial Therapy - Cardiovascular Risk Reduction
Covered when ALL of the following are met
Authorization issued for 12 months
Reauthorization - Cardiovascular Risk Reduction
Covered when ALL of the following are met
Authorization issued for 12 months; BMI requirement removed per change control
Initial Therapy - MASH
Covered when ALL of the following are met
Authorization issued for 12 months
Reauthorization - MASH
Covered when ALL of the following are met
Authorization issued for 12 months
Medications prescribed solely for weight loss are generally a benefit exclusion. This policy makes a limited exception: coverage is allowed only for Wegovy (semaglutide) injection or tablets when used to reduce major adverse cardiovascular events in adults with established cardiovascular disease and overweight/obesity, and for Wegovy injection for treatment of metabolic dysfunction-associated steatohepatitis (MASH) with fibrosis stage F2–F3. Coverage is not expanded to other weight‑loss indications outside these specified uses.
Certain clinical conditions are operational exclusions for authorization. Requests will be excluded when the patient has a diagnosis of diabetes or an HbA1c > 6.5% or when the patient has New York Heart Association (NYHA) class IV heart failure. These exclusions apply to Wegovy requests under this policy and must be documented to avoid denial.
Key Clinical Thresholds
Provider Actions and Documentation
Prior Authorization Required
Prior authorization required: Wegovy (semaglutide) injection or tablet for cardiovascular risk reduction and other indicated uses. Providers must obtain prior authorization before initiating therapy for eligible patients.
- Applies to Wegovy injection or tablet for reduction of major adverse cardiovascular events (see clinical criteria).
- Authorization issued for 12 months when criteria are met.
Required Documentation — Incomplete Requests
Requests missing required documentation will be considered incomplete and may be denied or pended until records are provided. Submit medical records that demonstrate all eligibility components.
- Documentation must include patient age (≥45) and BMI (≥27 kg/m2).
- Documentation must show established cardiovascular disease (e.g., prior MI, prior ischemic or hemorrhagic stroke, or symptomatic PAD with supporting evidence such as ABI <0.85, peripheral revascularization, or amputation due to atherosclerotic disease).
- For MASH/NASH indications, submit documentation of fibrosis stage F2 or F3 confirmed by VCTE (FibroScan), MRE, or liver biopsy within the past 12 months.
- Include evidence of use in combination with reduced calorie diet and increased physical activity, and any required specialist consultation (e.g., gastroenterologist or hepatologist for MASH).
Supply Limits May Apply
Supply limits may be in place. Check benefit-specific limits and quantity restrictions prior to prescribing to ensure coverage and avoid claim denials.
- Quantity or supply limits vary by benefit plan and may affect approval.
- Confirm plan-level pharmacy benefit rules and any step-therapy or prior-authorizationspecific fill limits.
Background
Wegovy (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Wegovy injection and tablets are 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/obesity. Wegovy injection is additionally approved for treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH, formerly NASH) with moderate to advanced fibrosis (consistent with stages F2–F3), and for weight reduction indications described in the product labeling.
Definitions
Initial Therapy Rules
Initial therapy rules
Initial authorization criteria by indication
12-month authorization
12-month authorization
Continuation / Reauthorization Criteria
MASH continuation
Reauthorization requirements for continued coverage
Authorization issued for 12 months
Step Therapy and Concomitant Treatments
| Patient history | Required concurrent secondary prevention therapies |
|---|---|
| History of myocardial infarction (MI) | Cholesterol-lowering agent (e.g., statin, PCSK9 inhibitor); beta blocker (e.g., carvedilol, metoprolol, bisoprolol); ACE‑I or ARB or ARNI; antiplatelet agent (e.g., aspirin, clopidogrel) |
| History of ischemic or hemorrhagic stroke | Cholesterol-lowering agent (e.g., statin, PCSK9 inhibitor); ACE‑I or ARB or ARNI; antiplatelet agent (e.g., aspirin, clopidogrel) |
| History of symptomatic peripheral arterial disease (PAD) (e.g., intermittent claudication with ABI <0.85 at rest, peripheral revascularization, or amputation from atherosclerotic disease) | Cholesterol-lowering agent (e.g., statin, PCSK9 inhibitor); ACE‑I or ARB or ARNI; antiplatelet agent (e.g., aspirin, clopidogrel) |
Quantity Limits
Site of Care
No site-of-care specification provided
No site-of-care restriction is specified in the policy for Wegovy administration or dispensing.
Revision History
Policy effective date for the Wegovy (semaglutide) program covering cardiovascular risk reduction and MASH only.
Removed BMI requirement from cardiovascular disease (CVD) reauthorization criteria and updated policy to include Wegovy tablets and differentiate indications by formulation.
Added coverage for MASH (metabolic dysfunction-associated steatohepatitis) indication for Wegovy injection and updated references.
Annual review with updated references.
Program created / new prior authorization program for Wegovy (semaglutide) covering cardiovascular risk reduction and MASH only.
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