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North Carolina Medicaid

Does North Carolina Medicaid cover Wegovy?

Yes. North Carolina Medicaid covers Wegovy for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.

Policy on file; the document isn't available to view online yet.

  • Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review June 4, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Weight Loss (1 plan type)

Applies to Medicaid plans.

Covered with requirements

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
  • Renewal: At least 5% weight loss from the starting weight.
  • Renewal: At least 4% reduction in BMI.
  • Renewal: 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.

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: North Carolina Medicaid Medicaid prior authorization policy

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Full requirements: Wegovy for Heart Disease Risk Reduction (1 plan type)

Applies to Medicaid plans.

Covered with requirements

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
  • Renewal: 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: North Carolina Medicaid Medicaid prior authorization policy

Open on its own page →

Full requirements: Wegovy for Liver Disease (MASH) (1 plan type)

Applies to Medicaid plans.

Covered with requirements

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
  • Renewal: 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: North Carolina Medicaid Medicaid prior authorization policy

Open on its own page →

Questions people ask
Does North Carolina Medicaid cover Wegovy?
Yes. North Carolina Medicaid covers Wegovy for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with North Carolina Medicaid?
Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 12 months. Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Liver Disease (MASH) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does North Carolina Medicaid require to renew Wegovy?
Weight Loss — Applies to Medicaid plans. At least 5% weight loss from the starting weight. At least 4% reduction in BMI. 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. Heart Disease Risk Reduction — Applies to Medicaid plans. 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. Liver Disease (MASH) — Applies to Medicaid plans. 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.
How current is this information?
The oldest review date among the policies on this page is June 4, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under North Carolina Medicaid: Zepbound

Wegovy under other plans: BCBS North Carolina, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid, EmblemHealth

All insurance plans · All medications

Summary of North Carolina Medicaid's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.