Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Adult Weight Management
All of:
- Age ≥ 18 years
- Prescriber provides baseline weight and BMI
- Treatment plan includes comprehensive adjunct lifestyle interventions (diet modification, physical activity, behavioral therapy)
- Patient able to titrate and maintain therapeutic dose per FDA-approved labeling
- Dose does not exceed 2.4 mg SC once weekly
Plus any one of:
- BMI ≥ 30 kg/m2
- BMI ≥ 27 kg/m2 AND at least one weight-related comorbidity (Table 2)
Pediatric Weight Management (age 12–17)
All of:
- Age ≥ 12 and < 18 years
- BMI (standardized for age and sex) at or above the 95th percentile per Table 3
- Prescriber provides baseline weight and BMI
- Treatment plan includes comprehensive adjunct lifestyle interventions (diet modification, physical activity, behavioral therapy)
- Patient able to titrate and maintain therapeutic dose per FDA-approved labeling
- Dose does not exceed 2.4 mg SC once weekly
Documentation to bring
- Baseline weight and BMI documentation
- Documentation of comprehensive adjunct lifestyle intervention plan (diet, physical activity, behavioral therapy)
- Documentation confirming patient meets BMI threshold (≥30 kg/m2, or ≥27 kg/m2 with comorbidity for adults; ≥95th BMI percentile for age/sex for pediatric patients)
- Documentation of qualifying weight-related comorbidity (if using BMI ≥27 pathway)
- Claims history or supporting documentation of prior medication use if applicable
Quantity limits
- 2.4 mg — Per FDA-approved dosing; dose not to exceed 2.4 mg SC once weekly
Approval and renewal
- Renewal: every 6 months
- Renewal: At least 5% weight loss from the starting weight.
- Renewal: At least 4% reduction in BMI.
- Renewal: Adults: must have lost 5% of pretreatment weight at 12 weeks (maintained), OR 10% of pretreatment weight at 28 weeks (maintained). Adolescents (12–<18): must have >4% reduction in baseline BMI (maintained). First renewal: 6 months; subsequent renewals: 12 months. NOTE: The high-cost 'Table 4' additional renewal weight loss thresholds (5%/10%/15%) do NOT apply to Wegovy as of 6/1/2025.
Not covered when
- Professional samples may not be used to establish patient history of medication usage
- Previous failure of a Table 4 high-cost agent requires minimum 1-year waiting period before further approval (exceptions: patient was within 1% of required weight loss and requested agent is expected to be more efficacious per FDA-approved labeling; or drug shortage documented by FDA or pharmacy wholesaler report) — NOTE: Table 4 does NOT apply to Wegovy as of 6/1/2025
- Patients with T2DM must use the formulation indicated for T2DM (applies to Table 4 agents; Wegovy exempt from Table 4 as of 6/1/2025)
Policy note: This is a Kansas Medicaid (KMAP) PA policy. Wegovy is exempt from the 'Additional General Criteria' (Table 4 high-cost agent requirements, including the severe obesity BMI ≥40 threshold and 3-month lifestyle modification requirement for initial approval) as of 6/1/2025. Initial approval duration is 28 weeks (as of 6/1/2025). Preferred PDL drug must be used unless non-preferred PDL PA criteria are met. The policy also notes that switching between agents requires compelling rationale. Minor updates were made 6/1/2025.
Policy effective August 14, 2024 · verified June 4, 2026 · source: Anti Obesity Medications Pdf · View policy document (PDF)