New York Medicaid

Does New York Medicaid cover Wegovy?

Quick answer · Heart Disease Risk Reduction

New York Medicaid covers Wegovy for heart disease risk reduction with prior authorization on Medicaid.

  • Medicaid: Covered with requirements. BMI of 40 or higher

Last verified June 3, 2026. Policy effective April 23, 2026. Source: nyrx_pdp_pdl.pdf. How we verify this data →

Check your card for your exact plan →

Wegovy for Heart Disease Risk Reduction

What New York Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

  • BMI of 40 or higher
  • 6 months of a documented diet and exercise program
  • Established cardiovascular disease

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction

All of:

  • Confirmed diagnosis of cardiovascular disease
  • Patient BMI >= 40 kg/m²
  • Patient is participating in lifestyle modifications that support cardiovascular health

Documentation to bring

  • Confirmation of cardiovascular disease diagnosis
  • Baseline BMI documentation (>= 40 kg/m²)
  • Documentation of participation in lifestyle modifications supporting cardiovascular health

Quantity limits

  • Two treatment attempts per lifetime (lifetime quantity limit)

Policy note: Lifetime quantity limit of two treatment attempts applies. Document is a partial excerpt from what appears to be the New York Medicaid (NYRx) DUR/PDL criteria document. Only the cv_risk_reduction indication for Wegovy is addressed in this excerpt. The BMI threshold of >= 40 kg/m² is notably higher than the FDA label threshold and typical commercial PA thresholds (27-30 kg/m²). Specific qualifying cardiovascular disease events are not enumerated in this excerpt. The standard PA fax form referenced is the New York Rx/Medicaid PA form.

Policy effective April 23, 2026 · verified June 3, 2026 · source: nyrx_pdp_pdl.pdf

Why Wegovy requests get denied by New York Medicaid

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Wegovy and Ozempic are the same molecule with different approved uses; a request for Wegovy under a diagnosis that matches Ozempic is routinely denied.
  2. BMI not documented in the chart notes (or documented without a baseline weight and date).
  3. No documented diet and exercise program.

Frequently asked questions

Does New York Medicaid cover Wegovy?
New York Medicaid covers Wegovy for heart disease risk reduction with prior authorization on Medicaid.
What BMI do you need for Wegovy under New York Medicaid?
For heart disease risk reduction on Medicaid plans, New York Medicaid requires a BMI of 40 or higher.
How current is this information?
This page reflects New York Medicaid's written policy as of April 23, 2026, last verified against the source document on June 3, 2026.

Other medications under New York Medicaid

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes New York Medicaid's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.