Delaware Medicaid coverage for Wegovy (Weight Loss)

What you need to qualify

• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (CVD, heart_failure, CKD, hypertension, hyperlipidemia, PAD, OSA, and T2DM)
• BMI at or above the 95th percentile for age and sex
• Diagnosis documented with a code
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Member's relevant medical records and/or pharmacy profile
• Appropriate baseline diagnostic and safety laboratory results with dates
• Documentation of current weight, height, and BMI
• Documentation of reduced calorie diet
• Documentation of increased physical activity
• If BMI is between 27-30 kg/m2: clinical co-morbid diagnosis with ICD-10 code
• Confirmation that member is NOT currently on another GLP-1 agonist
• Confirmation that member has no contraindicated conditions/medications with requested GLP-1
• For non-preferred agent: documentation that preferred medications have been tried with results
• Pharmacy claims history or pharmacy profile

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Adults must have lost >= 5% of baseline body weight; adolescents must have lost >= 4% of baseline body weight. If more than 50% of lost weight is regained or total weight loss from baseline is ever < 5% (adults) or < 4% (adolescents), PA may not be renewed for at least one year. Initial approval re-documentation not required at reauthorization as long as weight loss threshold is met. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Currently on another GLP-1 agonist
• Has a contraindicated condition/disease with the requested GLP-1 agonist
• Currently on a contraindicated medication with the requested GLP-1 agonist
• Off-label indications without two peer-reviewed articles demonstrating safety and efficacy

Policy note: Document is a class-level PA form for all GLP-1 agonists for weight management, MASH, or prevention of MACE from Delaware Medicaid (DMAP). Initial authorization is for up to 6 months in <= 30-day supplies. Re-authorization is for 6 months in <= 90-day supplies. Pediatric continuation threshold is >= 4% weight loss. If >50% of lost weight is regained or total weight loss is ever below threshold, PA may not be renewed for at least one year.

Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy