Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- Diagnosis documented with a code
- Established cardiovascular disease
Qualification pathways
You can qualify through any one of these.
Initial approval — CV risk reduction indication
All of:
- Established cardiovascular disease diagnosis documented in patient record
- Patient has obesity or overweight
- Documentation supports FDA-approved indication related to cardiovascular disease
- Failure of 30-day treatment trials with at least two preferred cardiac agents in the same class within the past 6 months, OR documented allergy or contraindication to all preferred agents in the class
Stable therapy pathway (alternative to step therapy)
All of:
- Documented stable therapy on Wegovy for 60 consecutive days or greater
Documentation to bring
- Documentation of appropriate diagnosis in patient record
- Documentation supporting FDA-approved cardiovascular disease indication
- Evidence of established cardiovascular disease with obesity or overweight
- Documentation of 30-day treatment trial failures with at least two preferred cardiac agents in the same class within past 6 months, OR documented allergy or contraindication to all preferred agents in the class
- For renewals: member weight records dated within the last 90 days
- For renewals: prescriber attestation that member requires Wegovy for cardiovascular risk reduction and that benefit outweighs GLP-1 associated risks
- For renewals: medical records documenting appropriate diagnosis
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for Prescriber must document: (1) member weight records dated within the last 90 days, (2) member requires Wegovy for cardiovascular risk reduction, and (3) the benefit of cardiovascular risk reduction outweighs the risk associated with use of GLP-1 agents, and (4) medical records document appropriate diagnosis.
Policy note: This policy falls under the 'Cardiac Agents' PA class for Alabama Medicaid. Wegovy is listed as a cardiac agent for CV risk reduction only — no weight loss or other indication is addressed in this document. The standard cardiac agent step-therapy requirement (failure of 30-day trials with at least two preferred cardiac agents in the same AHFS class within the past 6 months, OR allergy/contraindication to all preferred agents) applies unless the stable therapy pathway (60+ consecutive days on the requested medication) is met. Approval duration is 6 months (an explicit exception to the standard 12-month cardiac approval). Renewals require weight documentation within 90 days, clinical justification for continued use, and appropriate diagnosis. Medical justification (peer-reviewed literature, medical records, or other requested information) may also be used. EPA (electronic prior authorization) is available. Verbal PA requests meeting prior usage requirements may be accepted.
Policy effective August 15, 2025 · verified June 3, 2026 · source: Pa policy