Medicaid
Covered (preferred drug)What you need to qualify
- Age 12 and older
- BMI of 35 or higher
- BMI of 27 or higher with a weight-related condition (heart failure with preserved ejection fraction, uncontrolled hypertension, CKD stage 3a or above, OSA, pre-diabetes, MI, stroke, MASH with moderate to advanced liver fibrosis, symptomatic peripheral artery disease, and T2DM)
- BMI at or above the 95th percentile for age and sex
Qualification pathways
You can qualify through any one of these.
Pediatric (ages 12-17): Obesity/Overweight - Initial Approval
All of:
- Appropriate diagnosis
- Member is >= 12 years and < 18 years of age
- Member weight documented within 90 days prior to initiation of pharmacotherapy
- Member BMI is >= 95th percentile for age and gender (within 90 days prior to initiation)
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity is <= 4 pens/28 days
Adult (>= 18 years): BMI >= 35 kg/m2 (no comorbidity required)
All of:
- Appropriate diagnosis
- Member is >= 18 years of age
- Member weight documented within 90 days prior to initiation
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity <= 4 pens/28 days (injection) or <= 1 unit/day (tablet)
- Member BMI is >= 35 kg/m2 (within 90 days prior to initiation)
Adult (>= 18 years): BMI >= 30 kg/m2 with specific high-severity comorbidity
All of:
- Appropriate diagnosis
- Member is >= 18 years of age
- Member weight documented within 90 days prior to initiation
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity <= 4 pens/28 days (injection) or <= 1 unit/day (tablet)
- Member BMI is >= 30 kg/m2 (within 90 days prior to initiation)
Plus any one of:
- Heart failure with preserved ejection fraction
- Uncontrolled hypertension (systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite concurrent treatment with two antihypertensive medications)
- Chronic kidney disease stage 3a or above
- Moderate or severe obstructive sleep apnea (AHI > 15 without central or mixed sleep apnea)
Adult (>= 18 years): BMI >= 27 kg/m2 with qualifying comorbidity
All of:
- Appropriate diagnosis
- Member is >= 18 years of age
- Member weight documented within 90 days prior to initiation
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity <= 4 pens/28 days (injection) or <= 1 unit/day (tablet)
- Member BMI is >= 27 kg/m2 (within 90 days prior to initiation)
Plus any one of:
- Pre-diabetes (A1c >= 5.7% and < 6.5%) and member is not a candidate for an anti-diabetic GLP-1 agent
- History of myocardial infarction
- History of stroke
- Noncirrhotic MASH with moderate to advanced liver fibrosis (stages F2 to F3)
- Symptomatic peripheral artery disease
- Type 2 diabetes mellitus
Documentation to bring
- Documentation of appropriate diagnosis
- Documentation of member age (>= 12 years for pediatric; >= 18 years for adult)
- Member weight dated within 90 days prior to initiation of pharmacotherapy for obesity
- BMI documentation (>= 35 kg/m2 for adults without comorbidity; >= 30 kg/m2 with high-severity comorbidity; >= 27 kg/m2 with qualifying comorbidity) OR BMI >= 95th percentile for pediatric members
- Documentation of qualifying weight-related comorbid condition where applicable
- Documentation that member has been counseled to continue reduced-calorie diet and increased physical activity
- Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity at or below limit (<=4 pens/28 days for injection; <=1 unit/day for tablet)
- For recertification (adults >= 18): member weight within last 90 days AND one of: weight loss >= 5% from baseline, improvement in secondary measures with attestation, OSA symptom improvement with records verifying AHI >= 15, or CV risk reduction documentation
- For recertification (pediatric <18): member weight within last 90 days, member is < 18 years, and one of: BMI reduction >= 5% or improvement in secondary measures with attestation
Quantity limits
- all injection strengths — 4 pens per 28 days
- tablet — 1 unit/day
Approval and renewal
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 5% reduction in BMI, and For members >= 18 years: weight loss >= 5% from baseline body weight; OR improvement in secondary measures (e.g., blood glucose, blood pressure) with attestation that improvement is related to anti-obesity therapy; OR improvement in OSA symptoms (less daytime sleepiness, fewer sleep arousals, fewer partner-reported snoring/pauses) with attestation it is related to anti-obesity therapy and medical records verifying baseline or current OSA diagnosis with AHI >= 15; OR member requires GLP-1 for cardiovascular risk reduction and benefit outweighs risk, with documented history of MI, ischemic or hemorrhagic stroke, or symptomatic PAD (intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease). For pediatric members (<18): weight loss >= 5% from baseline BMI; OR improvement in secondary measures with attestation it is related to anti-obesity therapy. Effective February 17, 2026, comorbid conditions and baseline BMI (prior to starting GLP-1) are used to determine continued eligibility; some members may no longer qualify at recertification. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Combination use with another GLP-1 receptor agonist is not permitted (GLP-1/GIP polypharmacy requires separate PA and transitioning off prior agent)
- For pediatric BMI >= 27 pathway with pre-diabetes comorbidity: member must not be a candidate for an anti-diabetic GLP-1 agent
Policy note: MassHealth (Massachusetts Medicaid) policy. Wegovy injection is designated as a Preferred Drug (PD). Wegovy tablet also covered under the same adult criteria. The policy notes: 'Effective February 17, 2026, for members stable on a weight loss GLP-1, comorbid conditions and baseline BMI (defined as the BMI prior to starting a GLP-1 medication) are used to determine eligibility for continued treatment. Some members currently utilizing a weight-loss GLP-1 medication may no longer be eligible under these revised criteria and will be denied coverage at the time of recertification.' MassHealth pharmacy claims history or additional documentation may be used to evaluate adherence. Pre-diabetes defined as A1c >= 5.7% and < 6.5%. OSA (moderate/severe) defined as AHI > 15 without central or mixed sleep apnea. Uncontrolled hypertension defined as systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite concurrent treatment with two antihypertensive medications. Policy directs prescribers to consider the Antidiabetic Agents PA Request form as appropriate. Last revised 05/2026; page last updated 05/13/26.
Policy effective January 1, 2024 · verified June 4, 2026 · source: Pa policy