Medicaid
Covered with requirementsWhat 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.
CVD/MACE Risk Reduction in Obese or Overweight Individuals
All of:
- Diagnosis of cardiovascular disease in obese or overweight individuals needing MACE risk reduction
- Member is 45 years of age or older
- BMI >= 27 kg/m2 (chart documentation within past 3 months)
- Member does not have Type 1 or Type 2 diabetes (prescriber attestation)
- Member will use in combination with reduced calorie diet and increased physical activity
- Member will not use with other semaglutide products or any other GLP-1 RA or combination products
- Dose does not exceed 2.4 mg/week
Plus any one of:
- Prior myocardial infarction (MI) — supported by chart documentation within past year
- Prior stroke (ischemic or hemorrhagic) — supported by chart documentation within past year
- Symptomatic PAD: amputation due to atherosclerotic disease, OR history of peripheral arterial revascularization, OR intermittent claudication with ABI <0.85 at rest — supported by chart documentation within past year
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