Medicare AdvantagePrior AuthHigh impact
Wegovy (semaglutide) (Revised)
Humana·Cardiology, Gastroenterology, Internal Medicine +1 more·Medicare Advantage
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has updated its Wegovy (semaglutide) prior authorization policy, effective January 28, 2026, to include two distinct coverage pathways: (1) cardiovascular risk reduction in overweight/obese patients with established CVD (non-diabetic), and (2) treatment of metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (F2-F3). The policy requires prior authorization for both indications with specific clinical criteria and documentation requirements.
Action Required
By January 28, 2026: (1) Billing team must configure prior authorization workflow in billing system for Wegovy claims on Humana Medicare Advantage. (2) Providers must obtain prior auth before dispensing Wegovy for either indication. (3) For CVD indication: Verify member is overweight/obese WITHOUT diabetes, has established CVD history, is optimized on standard cardioprotective medications (aspirin, antiplatelet, anticoagulant, ACE-I/ARB, or beta-blocker), and is combining Wegovy with diet/exercise. (4) For MASH indication: Confirm diagnosis via liver biopsy, VCTE, or MRE; verify F2-F3 fibrosis staging; confirm no significant alcohol use (>20g/day women, >30g/day men); ensure combination with diet/exercise. (5) Update prior auth submission templates and provider education materials to reflect both covered indications and exclusion criteria. (6) Failure to obtain prior authorization will result in claim denials for Humana Medicare Advantage members.