Does Indiana Medicaid cover Wegovy?

Document explicitly states 'WEGOVY (SEMAGLUTIDE) INJECTION FORMULATION (NOT COVERED EXCLUSIVELY FOR WEIGHT LOSS)' and 'WEGOVY (SEMAGLUTIDE) ORAL FORMULATION (NOT COVERED EXCLUSIVELY FOR WEIGHT LOSS)'. No weight loss PA criteria are established; coverage is only available for CVD/MACE risk reduction and MASH indications.

Policy note: Explicitly not covered for weight loss as a standalone indication. Both injection and oral formulations carry the 'NOT COVERED EXCLUSIVELY FOR WEIGHT LOSS' designation.

Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf

What you need to qualify

• Age 45 and older
• BMI of 27 or higher
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (beta_blocker, RAS_inhibitor, and lipid_lowering_agent)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Chart documentation confirming CVD diagnosis (obese or overweight, MACE risk reduction)
• BMI documentation >= 27 kg/m2 obtained within past 3 months
• Documentation of qualifying CVD event (prior MI, prior stroke, or symptomatic PAD) obtained within past year
• Documentation of current GDMT use (beta-blockers and/or RAS inhibitors AND lipid-lowering agents) via chart documentation or claims history, OR medical justification why member cannot use these therapies (with dates of trial if applicable)
• Prescriber attestation that member does not have T1D or T2D
• Prescriber attestation of diet/physical activity use
• Prescriber attestation of no concurrent GLP-1 RA or semaglutide products

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for At reauthorization: Prescriber attests member does not have T1D or T2D, member continues diet/physical activity, member will not use with other semaglutide/GLP-1 products. Member must continue GDMT (beta-blockers and/or RAS inhibitors AND lipid-lowering agents) or prescriber provides justification for inability to use GDMT. History of requested agent at least 84 days within past 112 days. No weight loss percentage threshold required at renewal. Age >=45, BMI >=27, and qualifying CVD event documentation are NOT re-verified at renewal per policy structure and at least 12 weeks on therapy before the first renewal.

Not covered when

• Type 2 diabetes excluded
• No concurrent use with other semaglutide products or any GLP-1 RA or combination products
• Dose must not exceed 2.4 mg/week
• Weight loss as the sole indication is explicitly not covered
• Type 1 diabetes

Policy note: This entry covers the INJECTION formulation for CV risk reduction. There is also a separate ORAL formulation of Wegovy for CV risk reduction — see notes. Both formulations require the same CVD/MACE criteria. The oral formulation additionally requires medical justification for use over the subcutaneous injection. Wegovy is explicitly labeled 'NOT COVERED EXCLUSIVELY FOR WEIGHT LOSS.' GDMT requirement includes beta-blockers and/or RAS inhibitors AND lipid-lowering agents; prescriber may provide justification for inability to use these. PAD qualifying criteria are detailed: amputation, revascularization history, or intermittent claudication with ABI <0.85.

Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf

What you need to qualify

• Age 18 and older
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy and FibroScan_VCTE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Chart documentation or claims history confirming MASH diagnosis
• Liver biopsy report (within past 2 years) with NAS score components and METAVIR fibrosis stage (F2-F3, no cirrhosis), OR Fibroscan report (within past 6 months) with LSM >=9.1 kPa and CAP >=280 dB/m
• Documentation of prescribing/consulting specialist (endocrinologist, gastroenterologist, or hepatologist)
• For members with concomitant T2D: documentation of Ozempic at 2 mg/week for at least 18 months (claims or chart), plus baseline and current (within past 6 months) liver biopsy and/or non-invasive test results demonstrating inadequate fibrosis/steatosis reduction
• Documentation of concurrent Rezdiffra (resmetirom) use or absence thereof; if concurrent, prescriber medical justification required
• Prescriber attestation of diet/physical activity use

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for At reauthorization: liver biopsy within past year demonstrating improvement or stabilization in fibrosis staging and NAS score from baseline, OR Fibroscan within past year demonstrating improvement or stabilization in CAP and LSM scores. Must have history of requested agent at least 84 days within past 112 days. No concurrent GLP-1 RA or semaglutide products. Prescriber attests continued diet/physical activity and at least 12 weeks on therapy before the first renewal.

Not covered when

• No concurrent use with another GLP-1 RA or combination product (including semaglutide-containing products)
• Concurrent use with Rezdiffra (resmetirom) requires prescriber medical justification
• Members with T2D must have failed Ozempic 2 mg/week for >=18 months with documented inadequate fibrosis/steatosis reduction before Wegovy can be used for MASH
• No evidence of cirrhosis (biopsy criterion)
• Dose must not exceed 2.4 mg/week

Policy note: Wegovy MASH criteria (injection formulation) require METAVIR F2-F3 (no cirrhosis) — stricter fibrosis staging than Ozempic MASH criteria (F1-F3). Fibroscan thresholds also differ: Wegovy requires LSM >=9.1 kPa and CAP >=280 dB/m; Ozempic MASH requires LSM >=6.43 kPa and CAP >=238 dB/m. Members with concomitant T2D face an additional hurdle: must have been on Ozempic 2 mg/week consistently for >=18 months with demonstrated inadequate response. Concurrent Rezdiffra use requires justification. Initial approval is 1-year. Specialist required.

Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf