Kansas Medicaid coverage for Wegovy (Weight Loss)

Medicaid

Covered with requirements

What you need to qualify

Age 12 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (T2DM, dyslipidemia, HTN, CVD, NAFLD/NASH, PCOS, OSA, asthma, osteoarthritis, urinary stress incontinence, GERD, cancer, depression, psychotic disorders, metabolic syndrome, prediabetes, female infertility, and male hypogonadism)
BMI at or above the 95th percentile for age and sex
6 months of a documented diet and exercise program

Qualification 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
To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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