Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
CV Risk Reduction (MACE) — Wegovy only
All of:
- Wegovy (non-preferred) — medical necessity for non-preferred use documented
- Participant is aged ≥ 45 years
- Documented baseline BMI ≥ 27 kg/m2
- Lack of diabetes mellitus diagnosis in the past 2 years
- Recent A1C < 6.5 within the past 3 months confirming absence of diabetes diagnosis
- Lack of any history of anti-diabetic pharmaceutical therapy in the past 2 years
- Documentation of current pharmaceutical therapy for cardiovascular disease
Plus any one of:
- Documented diagnosis of myocardial infarction
- Documented diagnosis of stroke
- Symptomatic peripheral arterial disease — intermittent claudication with ABI < 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to ASCVD
Documentation to bring
- Documentation of medical necessity for using Wegovy instead of preferred agent (Zepbound)
- Participant age documentation (≥ 45 years)
- Documented baseline BMI ≥ 27 kg/m2
- Documentation confirming no diabetes mellitus diagnosis in the past 2 years
- Recent A1C < 6.5 within the past 3 months
- Documentation confirming no anti-diabetic pharmaceutical therapy in the past 2 years
- Documented diagnosis of qualifying CV event: myocardial infarction, stroke, or symptomatic PAD (with supporting evidence: ABI < 0.85, revascularization procedure, or amputation due to ASCVD)
- Documentation of current pharmaceutical therapy for cardiovascular disease
Quantity limits
- 0.25 mg/0.5 mL pen, 0.5 mg/0.5 mL pen, 1 mg/0.5 mL pen — 2 mL per 28 days
- 1.7 mg/0.75 mL pen, 2.4 mg/0.75 mL pen — 3 mL per 28 days
Approval and renewal
- Renewal: Staying on a maintenance dose of at least 1.7 mg.
Not covered when
- Concurrent therapy with another GLP-1 receptor agonist
- Unable to complete titration/dose escalation to at least 1.7 mg/dose within 6 months of beginning therapy
- Diabetes mellitus diagnosis within past 2 years
- Any history of anti-diabetic pharmaceutical therapy in past 2 years
- A1C ≥ 6.5 on recent lab
Policy note: This is a Wegovy-specific pathway. Strictly requires absence of diabetes: no diabetes diagnosis in the past 2 years, no anti-diabetic pharmaceutical therapy in the past 2 years, and recent A1C < 6.5 (within 3 months). CVD pharma therapy is required but not specified beyond 'pharmaceutical therapy for cardiovascular disease.' Titration rules same as Wegovy weight loss: initial approval 4 weeks, per-dose approvals during titration, must reach maintenance dose of at least 1.7 mg/dose within 6 months.
Policy effective January 29, 2026 · verified June 3, 2026 · source: Policy 311 · View policy document (PDF)