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New York Medicaid · Heart Disease Risk Reduction

New York Medicaid coverage for Wegovy (Heart Disease Risk Reduction)

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

All Wegovy policies under New York Medicaid · Check your card