Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Approval — Adult (≥18 years)
All of:
- Patient meets age limit per FDA-approved label
- Documentation of initiation of or ongoing reduced calorie diet OR ongoing care of a registered dietitian nutritionist
- Documentation of initiation of or ongoing regimen of increased physical activity unless medically contraindicated
- No contraindications (disease state or current therapy) unless prescriber documents benefits outweigh risks
- No concurrent use of any other weight loss drug(s)
- Patient's weight at baseline (in kg) submitted at time of request
Plus any one of:
- BMI ≥ 30 kg/m2 with no risk factors
- BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (hypertension, T2DM, or dyslipidemia)
Initial Approval — Adolescent (12-17 years)
All of:
- Patient meets age limit per FDA-approved label
- BMI ≥ 30 kg/m2 AND body weight above 60 kg
- Documentation of initiation of or ongoing reduced calorie diet OR ongoing care of a registered dietitian nutritionist
- Documentation of initiation of or ongoing regimen of increased physical activity unless medically contraindicated
- No contraindications (disease state or current therapy) unless prescriber documents benefits outweigh risks
- No concurrent use of any other weight loss drug(s)
- Patient's weight at baseline (in kg) submitted at time of request
Renewal — Adult (≥18 years)
All of:
- At least 5% weight loss during the initial approval period
- Documentation of ongoing reduced calorie diet OR ongoing care of a registered dietitian nutritionist
- Documentation of ongoing regimen of increased physical activity unless medically contraindicated
- No contraindications (disease state or current therapy) unless prescriber documents benefits outweigh risks
Renewal — Adolescent (12-17 years)
All of:
- At least 5% reduction in baseline BMI during the initial approval period
- Documentation of ongoing reduced calorie diet OR ongoing care of a registered dietitian nutritionist
- Documentation of ongoing regimen of increased physical activity unless medically contraindicated
- No contraindications (disease state or current therapy) unless prescriber documents benefits outweigh risks
Subsequent Renewal (beyond 18 months)
All of:
- Meets all standard renewal criteria
- Documentation that patient maintains weight loss achieved during the initial approval period
Documentation to bring
- Baseline BMI documentation (≥30 kg/m2 without comorbidity, or ≥27 kg/m2 with at least one weight-related comorbidity for adults; ≥30 kg/m2 and body weight >60 kg for ages 12-17)
- Patient's baseline weight in kg
- Documentation of initiation of or ongoing reduced calorie diet OR documentation of ongoing care of a registered dietitian nutritionist
- Documentation of initiation of or ongoing regimen of increased physical activity (or medical contraindication)
- Documentation that no concurrent weight loss drugs are being used
- At renewal: documentation of ≥5% weight loss (adults) or ≥5% BMI reduction (adolescents) during initial approval period
- At subsequent renewals (beyond 18 months): documentation that weight loss achieved during initial approval period is maintained
Quantity limits
- per FDA-approved label — Per FDA-approved label quantity limits
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: At least 5% reduction in BMI.
- Renewal: Adults (≥18): at least 5% weight loss during initial approval period. Adolescents (12-17): at least 5% reduction in baseline BMI during initial approval period. Subsequent renewals beyond 18 months require meeting all renewal criteria plus documentation that patient maintains weight loss achieved during initial approval period.
Not covered when
- No concurrent use of any other weight loss drug(s)
- No contraindications (disease state or current therapy) unless prescriber documents benefits outweigh risks
Policy note: This policy is published by Minnesota Medicaid (MHCP). The Anti-Obesity Medications PA criteria page (March 2023) lists Wegovy as a covered drug requiring PA. Initial approval is 6 months; renewal is 12 months. The BMI percentile criterion (≥30 kg/m2 and body weight >60 kg for ages 12-17) is a proxy pediatric threshold rather than a stated percentile. All drugs on the Anti-Obesity list require prior authorization. The preferred/non-preferred status is deferred to the Preferred Drug List.
Policy effective March 1, 2023 · verified June 4, 2026 · source: Policy 372 · View policy document (PDF)