CurrentUnitedHealthcarePolicy N/A

Wegovy (semaglutide) coverage for cardiovascular risk reduction and MASH

Defines prior authorization requirements for coverage of Wegovy (semaglutide) injection and tablets for cardiovascular risk reduction in adults with established cardiovascular disease and obesity/overweight, and for Wegovy injection for treatment of MASH (noncirrhotic metabolic dysfunction-associated steatohepatitis). Applies to UnitedHealthcare pharmacy benefit prior authorization programs.

Policy Summary

PayerUnitedHealthcare

PolicyWegovy (semaglutide) coverage for cardiovascular risk reduction and MASH

Policy CodePolicy N/A

Change TypeMaterialadded MASH, removed BMI reauth requirement, added tablet formulation

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with medical records documenting age, BMI ≥ 27 kg/m2 and established cardiovascular disease for CVD indication or fibrosis F2–F3 confirmation for MASH.

SourceLink

POLICY UPDATE CHANGES

Coverage was added for Wegovy injection for MASH.

Removed BMI requirement in cardiovascular disease reauthorization criteria.

Policy updated to include Wegovy tablets and differentiate approved indications by formulation.

12 monthsApproval length

≥45Min age (CVD)

≥27BMI threshold

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Coverage Criteria

Initial Therapy

Initial authorization — Wegovy injection or tablet for cardiovascular risk reduction is covered when ALL of the following are met:

CVD Initial Authorization: Treatment is requested to reduce the risk of major adverse cardiovascular events

Age: Patient is 45 years of age or older>=45 years

Documentation of BMI and established CVD: Submission of medical records documenting BMI ≥ 27 kg/m2 and established cardiovascular disease as evidenced by one of the following: prior myocardial infarction (MI); prior ischemic or hemorrhagic stroke; or symptomatic peripheral arterial disease (PAD) evidenced by intermittent claudication with ankle-brachial index (ABI) < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic diseaseBMI >= 27 kg/m2; ABI <0.85 for PAD

Lifestyle: Used in combination with a reduced calorie diet and increased physical activity

Concomitant secondary prevention therapy: One of the following depending on event type: for history of MI the patient must be on therapy from each class unless contraindicated or intolerant: cholesterol-lowering medication (e.g., statin, PCSK9i), beta blocker (e.g., carvedilol, metoprolol, bisoprolol), ACE-I/ARB/ARNI, and an antiplatelet (e.g., aspirin, clopidogrel); for history of ischemic or hemorrhagic stroke the patient must be on cholesterol-lowering therapy, ACE-I/ARB/ARNI, and an antiplatelet unless contraindicated or intolerant; for symptomatic PAD the patient must be on cholesterol-lowering therapy, ACE-I/ARB/ARNI, and an antiplatelet unless contraindicated or intolerant

Classes vary by event type as listed in policy

Exclusions and approval length: Patient does not have a diagnosis of diabetes or HgA1c > 6.5% and does not have New York Heart Association (NYHA) class IV heart failure; authorization will be issued for 12 monthsA1c <= 6.5%; not NYHA class IV

Reauthorization

Reauthorization — Wegovy injection or tablet for CVD indication is covered when ALL of the following are met:

Lifestyle: Used in combination with a reduced calorie diet and increased physical activity

MASH Initial Therapy

Initial authorization — Wegovy injection for MASH is covered when ALL of the following are met:

Indication: Wegovy injection is being requested for the treatment of metabolic dysfunction-associated steatohepatitis (MASH)

Fibrosis confirmation: Submission of medical records documenting fibrosis stage F2 or F3 confirmed by one of: liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE, e.g., FibroScan), LSM by magnetic resonance elastography (MRE), or liver biopsy within the past 12 monthsF2 or F3; biopsy within 12 months

Lifestyle: Used in combination with a reduced calorie diet and increased physical activity

No concurrent initiation with resmetirom: Provider attests Wegovy injection will not be initiated at the same time as Rezdiffra (resmetirom) for treatment of the same indication

MASH Reauthorization

Reauthorization — Wegovy injection for MASH is covered when ALL of the following are met:

Clinical response: Documentation of positive clinical response to Wegovy injection (e.g., improvement in or stabilization of fibrosis)

No cirrhosis progression: Patient has not progressed to cirrhosis

Lifestyle and prescriber: Continued use in combination with a reduced calorie diet and increased physical activity; prescribed by or in consultation with a gastroenterologist or hepatologist; authorization will be issued for 12 months

Medications prescribed solely for the purpose of weight loss are commonly excluded from benefits. This policy makes a narrow exception by authorizing coverage only for the specific, non–weight-loss indications described: Wegovy (semaglutide) injection or tablets for cardiovascular risk reduction in adults with established cardiovascular disease and overweight/obesity, and Wegovy injection for treatment of MASH (noncirrhotic metabolic dysfunction-associated steatohepatitis) with fibrosis stage F2–F3. Coverage is limited to these indications and the formulations listed in the policy.

Requests for Wegovy for the cardiovascular risk–reduction indication will be denied when the patient meets any of the policy’s exclusion conditions. Specifically, coverage is not allowed if the patient has a diagnosis of diabetes or an HgA1c > 6.5%, or if the patient has New York Heart Association class IV heart failure. Authorization for eligible CVD requests is issued for 12 months.

Coding and Referenced Products

Referenced productsmixed

not specified

Policy references Wegovy (semaglutide) injection and tablets; no specific CPT/HCPCS/NDC codes listed in document

Age and BMI thresholds

Minimum ageAge ≥ 45 years

BMI requirementBMI ≥ 27 kg/m2

Authorization durationApproval issued for 12 months

MASH fibrosis stage

Required fibrosis stagesFibrosis stage F2–F3

Acceptable confirmation methodsLSM by VCTE (e.g., FibroScan), LSM by MRE, or liver biopsy

Timing of confirmationLiver biopsy must be within the past 12 months (implied same timing for LSM confirmation)

Provider Actions and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Wegovy (semaglutide) injection and tablets when requested to reduce risk of major adverse cardiovascular events, and for Wegovy injection when requested for treatment of metabolic dysfunction-associated steatohepatitis (MASH).

Applies to Wegovy (semaglutide) injections and tablets for CVD indication; applies to Wegovy injection for MASH indication
Authorization issued for 12 months when approved
Requests must meet the detailed clinical criteria for the requested indication

Documentation Required

Documentation Submission Required

Submission of medical records is required to document that the patient meets indication-specific criteria.

For CVD indication: documentation of BMI ≥ 27 kg/m2 and established cardiovascular disease (e.g., prior MI, prior stroke, or symptomatic PAD with supporting evidence)

Initial Therapy Criteria

Initial therapy

Initial authorization rules for drug coverage

CVD initial: See CVD Initial Authorization criteria set: treatment to reduce MACE risk, age >=45, BMI >=27 kg/m2, documented established CVD, required secondary prevention medications as appropriate, absence of diabetes (A1c <=6.5%) and not NYHA class IV heart failure

12-month approval

MASH initial: See MASH Initial Authorization criteria set: Wegovy injection for MASH with fibrosis F2-F3 confirmed by VCTE, MRE, or biopsy within 12 months; prescriber specialty; no concurrent initiation with resmetirom

12-month approval

Continuation and Reauthorization Criteria

MASH continuation

MASH reauthorization continuation criteria

Continued benefit: Documentation of positive clinical response (improvement or stabilization of fibrosis) and no progression to cirrhosis; continued use with diet and exercise; prescribed by or in consultation with a gastroenterologist or hepatologist

Authorization for 12 months

Step Therapy Requirements

Cardiovascular event	Required secondary prevention medication classes
Prior myocardial infarction (MI)	Cholesterol‑lowering therapy (e.g., statin, PCSK9i); beta blocker (e.g., carvedilol, metoprolol, bisoprolol); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel). Patient must be on therapy from each listed class unless there is a contraindication or intolerance.
Prior ischemic or hemorrhagic stroke	Cholesterol‑lowering therapy (e.g., statin, PCSK9i); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel). Patient must be on therapy from each listed class unless there is a contraindication or intolerance.
Symptomatic peripheral arterial disease (PAD)	Cholesterol‑lowering therapy (e.g., statin, PCSK9i); ACE‑I or ARB or ARNI; antiplatelet (e.g., aspirin, clopidogrel). Patient must be on therapy from each listed class unless there is a contraindication or intolerance.

Quantity Limits

Wegovy (semaglutide) — supply limits

Quantity/availabilityWegovy (semaglutide) may be subject to supply limits per additional clinical rules

Program noteAdditional clinical rules may impose supply limits for Wegovy

Authorization periodApprovals (when granted) are issued for 12 months

Site of Care

Note

No specific site-of-care restrictions

Policy specifies no site-of-care restrictions; there are no stated infusion center or other site limitations for Wegovy in this policy.

Definitions

MASH definition

DefinitionMetabolic dysfunction-associated steatohepatitis (MASH), formerly NASH

Indication-specific requirementMASH requiring moderate to advanced liver fibrosis consistent with stages F2–F3

Treatment formulationWegovy injection is the formulation approved for MASH treatment

Combination therapyUsed in combination with a reduced calorie diet and increased physical activity

Background

Wegovy (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist. The injection and tablet formulations are indicated, in combination with a reduced-calorie diet and increased physical activity, to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) in adults with established cardiovascular disease who have obesity or are overweight. Wegovy is also indicated to reduce and maintain weight loss (in adults and, for the injection formulation, certain pediatric patients), and the injection formulation is additionally approved for treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced fibrosis (stages F2–F3).