Clinical Policy: Semaglutide (Wegovy) - CP.PMN.295 - Approval Criteria and Coding Implications

Oct 12, 2026

Clinical policy CP.PMN.295 defines clinical criteria for medical necessity of Semaglutide (Wegovy) injections and tablets under HIM/ICHRA and Medicaid. It summarizes FDA-approved indications, including cardiovascular event risk reduction, long-term weight management, and treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH). The policy requires submitted documentation that members meet all initial approval conditions, including established CVD history, BMI thresholds, age, participation in a physician-directed weight loss program, and specific dosing limits, with approval duration set to 6 months.

LanguageEnglish

CategoryForms

FormatPDF

Pages13

Reading Time5 min

AccessFree to download

Description

FDA Approved Indication(s)

Limitation(s) of use

Policy/Criteria

Initial Approval Criteria

Cardiovascular Event Prevention

Weight Management

Metabolic Dysfunction-Associated Steatohepatitis (MASH)

Clinical Policy: Semaglutide (Wegovy) Reference Number: CP.PMN.295 Effective Date: 06.01.24 Last Review Date: 09.26 Line of Business: HIM/ICHRA, Medicaid Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Semaglutide (Wegovy®) is a glucagon-like peptide-1 (GLP-1) receptor agonist. FDA Approved Indication(s) 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 (CVD) and either obesity or overweight. • To reduce excess body weight and maintain weight reduction long term in: o Adults with obesity and adults with overweight in the presence of at least one weightrelated comorbid condition. o Pediatric patients aged 12 years and older with obesity (Wegovy injection only). Wegovy injection is additionally indicated for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known alcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults. Continued approval for this indication may be contingent upon the verification and description of clinical benefit in a confirmatory trial. Limitation(s) of use: Concomitant use with other semaglutide-containing products or with anyother GLP-1 receptor agonist is not recommended. Policy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria. It is the policy of health plans affiliated with Centene Corporation® that Wegovy injection and tablets are medically necessary when the following criteria are met: I. Initial Approval Criteria A. Cardiovascular Event Prevention (must meet all): 1. Member has at least one of the following established CVD (a, b, or c): a. History of myocardial infarction; b. History of stroke; c. Symptomatic peripheral arterial disease (PAD) (see Appendix D); 2. Age ≥ 18 years; 3. Body mass index (BMI) ≥ 27 kg/m2 ; 4. Prescriber attestation that member is currently receiving cardiovascular standard of care management (see Appendix D); 5. For members with concurrent type 2 diabetes mellitus (T2DM), both of the following (a and b):* * For Illinois HIM requests, the step therapy requirements below do not apply as of 1/1/2026 per IL HB 5395 a. Member has received optimal diabetic standard of therapy as evidenced by a trial of ≥ 3 consecutive months of three of the following, unless clinically significant adverse effects are experienced or all are contraindicated; * i. Ozempic® or Rybelsus® ; ii. Trulicity® ; iii. Liraglutide (generic Victoza®) ; iv. Mounjaro® ; *Prior authorization may be required b. If member is currently receiving a GLP-1 receptor agonist and is requesting to switch to Wegovy therapy, medical justification* supports necessity for Wegovy; *Intolerance due to common adverse effects of the GLP-1 receptor agonists class such as gastrointestinal symptoms is not considered acceptable medical justification 6. Wegovy is not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist(s); 7. Documentation supports member's participation in a physician-directed weight loss program that involves a reduced calorie diet, increased physical activity, and behavioral modification that meets both of the following (a and b): a. Been actively enrolled in a physician-directed weight loss program for at least 6 months; b. Will continue to be enrolled in a physician-directed weight loss program while concomitantly prescribed Wegovy; 8. Documentation of member’s baseline body weight in kg; 9. Request m

FAQs

What approval documentation must be submitted to support coverage of Wegovy?

The provider must submit documentation such as office chart notes, lab results, or other clinical information supporting that the member meets all approval criteria.

What key clinical requirements are included for initial cardiovascular event prevention approval?

Requirements include established CVD history, age ≥ 18, BMI ≥ 27 kg/m2, prescriber attestation of current cardiovascular standard of care management, and (for members with concurrent T2DM) evidence of optimal diabetic standard of therapy plus additional conditions.

What limitations apply to Wegovy use with other medications?

Concomitant use with other semaglutide-containing products or with any other GLP-1 receptor agonist is not recommended, and Wegovy must not be prescribed concurrently with other semaglutide-containing products or other GLP-1 receptor agonists.

Oct 12, 2026

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