Medicaid
Covered with requirementsWhat 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