Louisiana Medicaid coverage for Wegovy (Heart

Medicaid

Covered with requirements

What you need to qualify

Age 45 and older
BMI of 27 or higher
6 months of a documented diet and exercise program
Established cardiovascular disease (MI, stroke, and PAD)
On guideline-directed medical therapy (optimized_pharmacotherapy_for_CVD)
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial Approval: CV Risk Reduction in Overweight/Obesity without Diabetes

All of:

Recipient is 45 years of age or older on the date of the request
Documented BMI >= 27 kg/m² (date and results of most recent BMI calculation stated on request)
Recipient does NOT have type 1 or type 2 diabetes
Recipient will not use medication with other semaglutide products or any other GLP-1 receptor agonists
Prescriber attests that semaglutide will be used as adjunct to standard of care therapy including: optimized pharmacotherapy for established CVD, individualized healthy lifestyle counseling, and behavioral modification (reduced calorie diet and increased physical activity)
Established cardiovascular disease documented by at least ONE qualifying event

Plus any one of:

Prior myocardial infarction
Prior stroke (ischemic or hemorrhagic)
Peripheral arterial disease: intermittent claudication with ABI < 0.85 at rest
Peripheral arterial disease: history of peripheral arterial revascularization procedure
Peripheral arterial disease: amputation due to atherosclerotic disease

Continuation/Maintenance Approval

All of:

Prescriber attests continued adjunct standard of care therapy (optimized CVD pharmacotherapy, lifestyle counseling, behavioral modification)
Request is for maintenance dose of 1.7mg or 2.4mg once weekly (if appropriate per titration schedule)
Recipient is currently receiving medication (evidenced by paid pharmacy claims) OR documentation shows recipient met initial criteria and received medication for at least 30 days
Weight loss or clinical justification criterion met

Plus any one of:

Recipient lost >= 5% of baseline body weight OR has maintained initial 5% weight loss (baseline and current weights with dates submitted)
Recipient did NOT reach/maintain >= 5% weight loss but clinical justification for continuation is provided (3-month renewal only; subsequent renewal requires > 5% weight loss)

Documentation to bring

Louisiana Uniform Prescription Drug Prior Authorization Form
Semaglutide (Wegovy) Treatment Agreement for Louisiana Medicaid Recipients (for initiation only)
Recipient's date of birth confirming age >= 45
Date and results of most recent BMI calculation showing BMI >= 27 kg/m²
Documentation of qualifying established cardiovascular disease event (prior MI, prior stroke, or PAD evidence including ABI result, revascularization procedure history, or atherosclerotic amputation)
Prescriber attestation that recipient does NOT have type 1 or type 2 diabetes
Prescriber attestation that medication will not be used with other semaglutide products or GLP-1 receptor agonists
Prescriber attestation of adjunct standard of care: optimized CVD pharmacotherapy, individualized healthy lifestyle counseling, and behavioral modification (reduced calorie diet and increased physical activity)
For continuation: evidence of current medication use via paid pharmacy claims OR documentation of meeting initial criteria and >=30 days of therapy
For continuation: documentation of baseline body weight prior to initiation and current weight with dates
For continuation: clinical justification if weight loss < 5% (required for 3-month extension only)

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, Recipient must have lost >= 5% of baseline body weight OR maintained initial 5% weight loss. If weight loss < 5%, clinical justification for continuation may be accepted for a 3-month renewal only; subsequent renewal requires > 5% weight loss. Prescriber must confirm continued adjunct standard of care therapy including optimized CVD pharmacotherapy, lifestyle counseling, and behavioral modification. Initial approval requirements (age >= 45, BMI >= 27, established CVD, no diabetes) are NOT re-verified at continuation — only weight loss progress and maintenance dose are checked. If previous approval was 3 months and weight loss is still < 5%, do NOT approve, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Type 2 diabetes (excluded — must NOT have T2DM)
Concomitant use with other semaglutide products
Concomitant use with any other GLP-1 receptor agonist
Inability to tolerate 1.7mg weekly maintenance dose (medication should be discontinued)
Type 1 diabetes

Policy note: This is a Louisiana Medicaid policy specific to Wegovy for CV risk reduction (SELECT trial indication). The policy mirrors the SELECT trial population (age >= 45, BMI >= 27, established CVD, no diabetes). PAD qualification requires specific evidence: ABI < 0.85 at rest with intermittent claudication, OR history of peripheral arterial revascularization, OR amputation due to atherosclerotic disease. Continuation approval duration varies: 6 months if >5% weight loss achieved; 3 months only if <5% weight loss with clinical justification — but a subsequent renewal after the 3-month extension requires >5% weight loss. Policy created April 2024, implemented July 2024.

Policy effective July 1, 2024 · verified June 2, 2026 · source: Wegovy.05072024.pdf

Louisiana Medicaid coverage for Wegovy (Heart Disease Risk Reduction)