Prior Authorization Criteria — Wegovy (semaglutide)
Customize your policy alerts
Sign up for all West Virginia Bureau for Medical Services (Department of Human Services) policy alerts
Know when West Virginia Bureau for Medical Services (Department of Human Services) releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization criteria for coverage of Wegovy (semaglutide) under the West Virginia Bureau for Medical Services, limited to secondary prevention of major adverse cardiovascular events and treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH). Affects prescribers requesting PA for WV BMS beneficiaries.
No material clinical or coverage changes in this revision.
Coverage Criteria for Wegovy (semaglutide)
inv-01: Initial Approval — Reduction of Major Adverse Cardiovascular Events
Covered when ALL of the following are met:
inv-02: Initial Approval — Noncirrhotic MASH (F2–F3)
Covered when ALL of the following are met:
inv-20: Initial therapy — Initial approval rules (grouping / summary block for initial therapy)
Summary of initial approval rules for all covered indications.
Agents prescribed solely for the purpose of weight loss are typically a benefit exclusion under WV BMS. Coverage of Wegovy (semaglutide) is limited to secondary prevention of major adverse cardiovascular events and treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH); requests for weight‑loss‑only indications will generally be denied.
Coadministration of Wegovy with any other semaglutide-containing product or with any other GLP‑1 receptor agonist is not recommended and will not be allowed. The policy requires that the medication not be used concomitantly with other GLP‑1 agonist agents for both the cardiovascular and MASH indications.
Use of Wegovy for the cardiovascular (secondary prevention) indication is excluded in patients with diabetes: the criteria explicitly require that the patient does not have type 1 or type 2 diabetes and that HbA1c ≤ 6.5% (with HbA1c result provided within the last 6 months). Requests for patients with type 1 or type 2 diabetes will be denied for the CV indication.
Initial Therapy Criteria
inv-20: Initial therapy — Initial approval rules (detailed criteria tree for starting therapy)
Detailed initial approval criteria (full logic).
Continuation of Therapy Criteria
inv-03: Continuation of Therapy — Cardiovascular indication
Covered when ALL of the following are met:
inv-04: Continuation of Therapy — MASH indication
Covered when ALL of the following are met:
inv-21: CV continuation — Continuation criteria for cardiovascular indication (secondary/alternate grouping)
Continuation criteria for the cardiovascular indication (secondary/alternate grouping).
inv-22: MASH continuation — Continuation criteria for MASH indication (secondary/alternate grouping)
Continuation criteria for the MASH indication (secondary/alternate grouping).
Key Clinical Thresholds and Codes
Actions Required of Prescribers / Prior Authorization
PA required for CV secondary prevention
Prior authorization is required when Wegovy is requested for reduction of major adverse cardiovascular events in adults with established cardiovascular disease. Initial approvals may be authorized for 90 days; further approvals may be granted for six months after continuation criteria are met.
PA required for noncirrhotic MASH (F2–F3)
Prior authorization is required for Wegovy for treatment of noncirrhotic MASH (stage F2–F3). Initial approvals will be for 90 days; further approvals may be granted for one year after continuation criteria are met.
Manage diabetes with a diabetes‑approved GLP‑1 RA
When a patient has both type 2 diabetes and MASH, diabetes management should be with a GLP-1 receptor agonist that is approved for diabetes at the appropriate dose per the West Virginia Preferred Drug List.
Submit BMI, recent HbA1c, prior CV event, and behavior attestation
Provide the date and result of the most recent BMI calculation and an HbA1c level taken within the last 6 months; include documentation of the qualifying prior cardiovascular event (prior MI, prior stroke, or symptomatic PAD as defined) and attestation of behavioral modification (reduced calorie diet and increased physical activity).
- Date and result of most recent BMI (must be ≥ 27 kg/m2 for CV indication)
- HbA1c level within the last 6 months (must be ≤ 6.5% for CV indication)
- Documentation of prior MI, prior stroke, or symptomatic PAD (ABI ≤ 0.85 at rest, peripheral revascularization, or amputation due to atherosclerotic disease)
- Attestation of diet and exercise behavioral modification
Submit liver biopsy or elastography and counseling documentation for MASH
For MASH requests, submit confirmation of diagnosis by ONE of the allowed methods: a liver biopsy within the past year showing NAFLD activity score ≥ 4 with scores >1 in steatosis, ballooning, and lobular inflammation; or liver stiffness measurement by FibroScan or MRE. Also include documentation of stage 2–3 fibrosis and documentation of diet/exercise counseling/treatment within the past 12 months.
- Liver biopsy within past 1 year with NAFLD activity score ≥ 4 and >1 in steatosis, ballooning, and lobular inflammation; OR
- Liver stiffness measurement by FibroScan or MRE
- Documentation confirming stage 2 or 3 fibrosis
- Documentation of diet/exercise and weight‑loss counseling/treatment within past 12 months
Diabetes excludes CV indication (HbA1c > 6.5% excluded)
Requests for the cardiovascular indication will be denied if the patient has type 1 or type 2 diabetes or an HbA1c greater than 6.5%.
Weight‑loss‑only requests are excluded
Coverage is limited to secondary prevention of cardiovascular events and treatment of MASH; agents used solely for weight loss are typically a benefit exclusion and requests for Wegovy for weight loss alone are subject to exclusion.
Definitions and Terms
Step Therapy / Related Management Rules
| Step | Requirement |
|---|---|
| {"text":"1","status":""}|{"text":"For patients with both type 2 diabetes and MASH, diabetes therapy should be managed with a GLP-1 receptor agonist approved for that indication at the appropriate dose (per the West Virginia Preferred Drug List).","status":""} | |
| {"text":"2","status":""}|{"text":"Medication must not be used concomitantly with other GLP-1 receptor agonist agents or semaglutide-containing products.","status":""} | |
| {"text":"3","status":""}|{"text":"Prescriber must be an M.D./D.O. or in consultation with a specialty-trained prescriber in gastroenterology or hepatology as applicable to MASH treatment.","status":""} |
Background
Semaglutide (Wegovy) is a glucagon‑like peptide‑1 (GLP‑1) receptor agonist. It is indicated to reduce the risk of major adverse cardiovascular events (CV death, non‑fatal myocardial infarction, or non‑fatal stroke) in adults with established cardiovascular disease and overweight or obesity, and it is also indicated for the treatment of noncirrhotic metabolic dysfunction‑associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (stage F2–F3). WV BMS limits coverage to the CV secondary prevention and MASH indications and specifies limitations on coadministration with other GLP‑1 agents.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.