Kentucky Medicaid coverage for Wegovy (Heart

Medicaid

Covered with requirements

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 (statin, PCSK9_inhibitor, beta_blocker, ACE_inhibitor, ARB, ARNI, and antiplatelet)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

MACE Risk Reduction — Initial Approval

All of:

Patient age >= 45 years
Being prescribed for MACE risk reduction (cardiovascular death, non-fatal MI, or non-fatal stroke)
Documentation within the past year of pre-existing CV disease (prior MI, prior stroke, or symptomatic PAD)
BMI >= 27 kg/m²
Documentation that medication will be used with reduced calorie diet and increased physical activity
Optimization on specified lipid-lowering therapy (moderate-to-high intensity statin or PCSK9 inhibitor) per claims history AND documentation
No history of type 2 diabetes
Current A1C < 6.5%
No NYHA class IV heart failure
No end-stage kidney disease or dialysis
No plans to undergo coronary, carotid, or peripheral revascularization
No personal or family history of MTC or MEN2
Not pregnant, breastfeeding, or intending to become pregnant without highly effective contraception
Requested dose does not exceed maximum FDA-approved dose
Not used in combination with another GLP-1 or dual GLP-1/GIP receptor agonist

Plus any one of:

On beta-blocker
On RAS inhibitor (ACE-I, ARB, or ARNI)
On antiplatelet therapy (e.g., aspirin, clopidogrel)
Prescriber provides medical justification for why patient cannot use lipid-lowering therapies AND beta-blockers, RAS inhibitors, or antiplatelet therapies

Documentation to bring

Documentation (e.g., progress note) within the past year confirming pre-existing cardiovascular disease (prior MI, prior stroke, or symptomatic PAD with supporting evidence)
Claims history showing optimization on moderate-to-high intensity statin or PCSK9 inhibitor
Documentation of concurrent use of beta-blocker, RAS inhibitor (ACE-I/ARB/ARNI), or antiplatelet therapy; OR medical justification for why these cannot be used (with dates of trial if applicable)
Baseline BMI documentation (>= 27 kg/m²)
Documentation that medication will be used with reduced calorie diet and increased physical activity
Current A1C lab result confirming < 6.5%
Attestation that patient does not have NYHA class IV heart failure, ESKD/dialysis, planned revascularization, personal/family history of MTC or MEN2

Quantity limits

all strengths — pen injector — 4 pens per 28 days
all strengths — tablet — 1 tablet per day

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 Patient must have at least 5% reduction in baseline body weight OR provider documents assessment of lifestyle and diet interventions if weight loss goal not met. Patient must continue on cardiovascular disease therapy management. Exclusions (no T2DM history, A1C < 6.5%, no NYHA class IV HF, no ESKD/dialysis, no planned revascularization, no MTC/MEN2 history, no pregnancy/breastfeeding) are re-verified at renewal. No re-verification of age >=45, BMI >=27, or documentation of qualifying CV event at renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

History of type 2 diabetes
Current A1C >= 6.5%
NYHA class IV heart failure
End-stage kidney disease or dialysis
Plans to undergo coronary, carotid, or peripheral revascularization
Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Breastfeeding
Female of child-bearing potential not using highly effective contraception
Concurrent use of another GLP-1 or dual GLP-1/GIP receptor agonist
Pregnancy

Policy note: This is a Kentucky Medicaid PA policy administered by MedImpact. The CV qualifying events for PAD include: amputation due to atherosclerotic disease, history of peripheral arterial revascularization, or intermittent claudication with ABI < 0.85 at rest. For stroke, both ischemic and hemorrhagic qualify. GDMT requires optimization on lipid-lowering therapy (statin or PCSK9) as evidenced by claims history, PLUS at least one of: beta-blocker, RAS inhibitor, or antiplatelet; or medical justification for inability to use all three classes. Wegovy tablet is not mentioned as excluded for the CV indication (only excluded for MASH). Copyright 2025 MedImpact Healthcare Systems.

verified June 4, 2026 · source: wegovy_pa_criteria_1.3.2026.pdf

Kentucky Medicaid coverage for Wegovy (Heart Disease Risk Reduction)