North Carolina Medicaid

Does North Carolina Medicaid cover Wegovy?

Quick answer · Weight Loss

North Carolina Medicaid covers Wegovy for weight loss with prior authorization on Medicaid.

  • Medicaid: Covered with requirements. BMI of 30 or higher

Last verified June 4, 2026. Policy effective August 1, 2024. Source: download. How we verify this data →

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Wegovy for Weight Loss

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 12 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (HTN, T2DM, OSA, CVD, and dyslipidemia)
  • BMI at or above the 95th percentile for age and sex
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult (18+) — BMI ≥ 30

All of:

  • Age 18 or older
  • BMI ≥ 30 kg/m²
  • FDA approved for indication, age, weight, and does not exceed dosing limits
  • Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
  • Baseline weight and BMI documented within past 45 days on PA form
  • Beneficiary is new to therapy or attempting a repeat weight loss course
  • Currently on and will continue lifestyle modification (structured nutrition and physical activity)
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)

Adult (18+) — BMI ≥ 27 with comorbidity

All of:

  • Age 18 or older
  • BMI ≥ 27 kg/m²
  • At least one weight-related comorbidity/risk factor/complication (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
  • FDA approved for indication, age, weight, and does not exceed dosing limits
  • Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
  • Baseline weight and BMI documented within past 45 days on PA form
  • Beneficiary is new to therapy or attempting a repeat weight loss course
  • Currently on and will continue lifestyle modification (structured nutrition and physical activity)
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)

Adolescent (12–17) — BMI ≥ 95th percentile or ≥ 30

All of:

  • Age 12–17 years
  • FDA approved for indication, age, weight, and does not exceed dosing limits
  • Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
  • Baseline weight and BMI documented within past 45 days on PA form
  • Beneficiary is new to therapy or attempting a repeat weight loss course
  • Currently on and will continue lifestyle modification (structured nutrition and physical activity)
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)

Plus any one of:

  • BMI ≥ 95th percentile for age and sex
  • BMI ≥ 30 kg/m²

Adolescent (12–17) — BMI ≥ 85th percentile with severe comorbidity

All of:

  • Age 12–17 years
  • BMI ≥ 85th percentile for age and sex
  • At least one severe weight-related comorbidity/risk factor/complication
  • FDA approved for indication, age, weight, and does not exceed dosing limits
  • Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
  • Baseline weight and BMI documented within past 45 days on PA form
  • Beneficiary is new to therapy or attempting a repeat weight loss course
  • Currently on and will continue lifestyle modification (structured nutrition and physical activity)
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)

Documentation to bring

  • Baseline weight and BMI (measured within the past 45 days) documented on PA form
  • Documentation of preferred drug trial (3–6 months titration) or documented contraindication to preferred drug
  • Documentation that beneficiary is new to therapy or attempting a repeat weight loss course
  • For adults with comorbidity pathway: documentation of qualifying weight-related comorbidity (HTN, T2DM, OSA, CVD, or dyslipidemia)
  • For adolescent 85th percentile pathway: documentation of severe weight-related comorbidity

Quantity limits

  • titration doses — 2 mL per 28 days
  • maintenance doses — 3 mL per 28 days

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: 5% total pretreatment weight loss maintained. Adolescents (12 to <18): >4% reduction in baseline BMI maintained. Alternatively, adults or adolescents with documented weight loss deemed significant per prescriber even if 5%/4% thresholds not met, with rationale. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. At each renewal, provider must document review of medication list for possible dose reductions or discontinuation of comorbid medications no longer needed due to weight reduction effects. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Lactation
  • History of medullary thyroid carcinoma
  • Multiple endocrine neoplasia syndrome type 2 (MEN2)
  • Concurrent use with another GLP-1 receptor agonist
  • Pregnancy

Policy note: Policy applies to NC Medicaid beneficiaries enrolled on date of service. EPSDT provisions apply for beneficiaries under 21 years of age. If the preferred PDL drug exists for this indication, a trial of 3–6 months of the preferred drug (including adequate titration) is required before approval of a non-preferred agent, unless contraindicated. Titration can take up to 6 months for GLP-1s. Adolescent renewal threshold is >4% reduction in baseline BMI (not weight). The 12-month renewal duration applies to weight_loss indication; renewal requires prior PA approval through Medicaid.

Policy effective August 1, 2024 · verified June 4, 2026 · source: download

Wegovy for Heart Disease Risk Reduction

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 45 and older
  • BMI of 27 or higher
  • 3 months of a documented diet and exercise program
  • Established cardiovascular disease (MI, stroke, and symptomatic peripheral arterial disease)

Qualification pathways

You can qualify through any one of these.

Cardioprotection (CV risk reduction) — Adult ≥ 45 with established CVD and BMI ≥ 27

All of:

  • Beneficiary is 45 years of age or older
  • Documented baseline BMI ≥ 27 kg/m² prior to beginning GLP-1 therapy
  • Established cardiovascular disease (CVD) defined as history of myocardial infarction, stroke, or symptomatic peripheral arterial disease — documented on PA form
  • No personal or family history of medullary thyroid carcinoma
  • No multiple endocrine neoplasia syndrome type 2
  • At least 3 months of lifestyle modifications prior to starting Wegovy
  • Currently on and will continue lifestyle modification including structured nutrition and physical activity
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications

Documentation to bring

  • Documented baseline BMI ≥ 27 kg/m² prior to beginning GLP-1 therapy (on PA form)
  • Documentation of established CVD (history of MI, stroke, or symptomatic peripheral arterial disease) on PA form
  • Documentation of at least 3 months of lifestyle modifications prior to starting Wegovy
  • Beneficiary age ≥ 45 confirmed

Quantity limits

  • titration doses — 2 mL per 28 days
  • maintenance doses — 3 mL per 28 days

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for Medical documentation that beneficiary has improved while on medication AND individual clinical goals set by provider are being met OR beneficiary is continuing to make adequate progress towards treatment goals. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. Provider must document review of medication list at each renewal for possible dose reductions or discontinuation of comorbid medications. Note: Covered indication went into effect October 1, 2025; prior PA approval through Medicaid required before renewal.

Not covered when

  • Personal or family history of medullary thyroid carcinoma
  • Multiple endocrine neoplasia syndrome type 2 (MEN2)
  • Concurrent use with another GLP-1 receptor agonist
  • Pregnancy

Policy note: This cardioprotection/CV risk reduction indication is also accessible via the general weight management pathway for adults ≥ 45 with BMI ≥ 27 and established CVD. The Wegovy-specific cardioprotection section adds the requirement of at least 3 months of prior lifestyle modifications before starting therapy. Covered indication under Wegovy-specific criteria went into effect October 1, 2025 per the renewal criteria section. Duration of approval for Wegovy-specific indications (cardioprotection, MASH) is 6 months for initial and renewals.

Policy effective August 1, 2024 · verified June 4, 2026 · source: download

Wegovy for Liver Disease (MASH)

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 25 or higher
  • BMI of 23 or higher for patients of Asian descent
  • 6 months of a documented diet and exercise program
  • Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, liver_biopsy, MRE, ELF_test, and FibroSure, fibrosis stage F1 to F3
  • Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

NASH/MASH with F1–F3 fibrosis — Adult ≥ 18

All of:

  • Diagnosis of noncirrhotic NASH or MASH
  • Adult (18 years of age or over)
  • Medical records required
  • Stage F1, F2, or F3 fibrosis confirmed by BOTH: (1) FIB-4 score consistent with F1–F3 fibrosis adjusted for age, AND (2) at least one of: liver biopsy, VCTE/FibroScan, ELF score, MRE, or FibroSure
  • Requested agent is Wegovy
  • Being monitored for development of and/or treated for any comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
  • No decompensated cirrhosis
  • No moderate to severe hepatic impairment (Child-Pugh Class B or C)
  • No other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
  • Currently on and will continue lifestyle modification including structured nutrition and physical activity
  • Will NOT use in combination with another GLP-1 receptor agonist
  • No FDA-labeled contraindications

Plus any one of:

  • Baseline BMI > 25 kg/m² prior to beginning therapy
  • Baseline BMI > 23 kg/m² if beneficiary is of South Asian, Southeast Asian, or East Asian descent

Documentation to bring

  • Medical records confirming diagnosis of noncirrhotic NASH or MASH
  • FIB-4 score consistent with stage F1, F2, or F3 fibrosis (adjusted for age)
  • At least one confirmatory test result: liver biopsy, VCTE/FibroScan, ELF score, MRE, or FibroSure
  • Baseline BMI documentation (>25 kg/m², or >23 kg/m² for South/Southeast/East Asian descent)
  • Documentation of alcohol consumption (female <20 g/day, male <30 g/day)
  • Documentation of monitoring or treatment for comorbid conditions (CVD, diabetes, dyslipidemia, hypertension)
  • Documentation confirming absence of decompensated cirrhosis, Child-Pugh B/C hepatic impairment, and other liver disease

Quantity limits

  • titration doses — 2 mL per 28 days
  • maintenance doses — 3 mL per 28 days

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for Medical documentation that beneficiary has improved while on medication AND individual clinical goals set by provider are being met OR beneficiary is continuing to make adequate progress towards treatment goals. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. Provider must document review of medication list at each renewal for possible dose reductions or discontinuation of comorbid medications. Note: Covered indication went into effect October 1, 2025; prior PA approval through Medicaid required before renewal.

Not covered when

  • Decompensated cirrhosis
  • Moderate to severe hepatic impairment (Child-Pugh Class B or C)
  • Any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
  • Concurrent use with another GLP-1 receptor agonist
  • Medullary thyroid carcinoma history
  • Multiple endocrine neoplasia syndrome type 2 (MEN2)
  • Lactation
  • Pregnancy

Policy note: Fibrosis staging requires BOTH a FIB-4 score AND at least one additional confirmatory test (liver biopsy, VCTE/FibroScan, ELF, MRE, or FibroSure). No explicit lookback periods are specified for these tests in the document. The Asian descent BMI threshold (>23 kg/m²) applies to South Asian, Southeast Asian, and East Asian patients. The document labels this indication as NASH or MASH (noncirrhotic). Covered indication went into effect October 1, 2025 per renewal section.

Policy effective August 1, 2024 · verified June 4, 2026 · source: download

Why Wegovy requests get denied by North Carolina 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. Qualifying weight-related condition not documented with its own diagnosis code.
  4. No documented diet and exercise program.
  5. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does North Carolina Medicaid cover Wegovy?
North Carolina Medicaid covers Wegovy for weight loss with prior authorization on Medicaid.
What BMI do you need for Wegovy under North Carolina Medicaid?
For weight loss on Medicaid plans, North Carolina Medicaid requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.
How long does a Wegovy approval last with North Carolina Medicaid?
Initial approvals last 6 months, and renewals are granted in 12-month periods.
What does North Carolina Medicaid require to renew Wegovy?
At least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: 5% total pretreatment weight loss maintained. Adolescents (12 to <18): >4% reduction in baseline BMI maintained. Alternatively, adults or adolescents with documented weight loss deemed significant per prescriber even if 5%/4% thresholds not met, with rationale. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. At each renewal, provider must document review of medication list for possible dose reductions or discontinuation of comorbid medications no longer needed due to weight reduction effects.
How current is this information?
This page reflects North Carolina Medicaid's written policy as of August 1, 2024, last verified against the source document on June 4, 2026.

Other medications under North Carolina Medicaid

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes North Carolina 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.