Medicaid
Covered with requirementsWhat you need to qualify
- Age 45 and older
- BMI of 27 or higher
- Diagnosis documented with a code
- Established cardiovascular disease (MI, stroke, and PAD)
- On guideline-directed medical therapy (antiplatelet_agent, aspirin, platelet_aggregation_inhibitor, statin, ezetimibe, fibrate, PCSK9_inhibitor, beta_blocker, ACE_inhibitor, and ARB)
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction (MACE) — Initial Approval
All of:
- Age >= 45 years
- Diagnosis is reduction of Major Adverse Cardiovascular Events (MACE)
- BMI >= 27 kg/m²
- History of Type 1 or Type 2 diabetes mellitus
- At least one qualifying established cardiovascular event (MI, stroke, or symptomatic PAD)
- Receiving standard CV therapy (antiplatelet agent, lipid-lowering therapy, and/or antihypertensive) OR documented inability to take standard CV therapy due to side effects or medical condition
Plus any one of:
- History of myocardial infarction (heart attack)
- History of stroke
- Symptomatic Peripheral Artery Disease: intermittent claudication with ABI < 0.85 at rest
- Symptomatic Peripheral Artery Disease: peripheral arterial revascularization procedure (endarterectomy, angioplasty, stenting)
- Symptomatic Peripheral Artery Disease: amputation due to ASCVD
Documentation to bring
- ICD-10 diagnosis code(s)
- Patient age >= 45 years
- Confirmation that diagnosis is for MACE reduction
- Documentation of BMI >= 27 kg/m²
- Documentation of history of diabetes (Type 1 or Type 2)
- Documentation of qualifying CV event: MI with date, OR stroke with date, OR symptomatic PAD (type and date)
- List of current standard CV therapy medications OR explanation of why patient cannot take standard CV therapy
Not covered when
- Patients under age 21 must use EPSDT pathway (Standard PA Fillable form) per OAC Rule 5160-1-14
Policy note: Per Ohio Administrative Code (OAC) 5160-9-03, drugs used for the treatment of obesity are NOT covered by the Ohio Department of Medicaid. This PA form is specifically for the MACE reduction indication only. Notably, the GDMT requirement can be satisfied with documentation that the patient is unable to take standard CV therapy due to side effects or another medical condition. The diabetes history requirement (Q4) includes both Type 1 and Type 2 diabetes — this mirrors the SELECT trial population and does NOT exclude diabetes. This differs from the FDA labeling population (overweight/obese without diabetes) used for Wegovy's CV indication more broadly; here diabetes is REQUIRED as per the PA form.
Policy effective February 4, 2025 · verified June 4, 2026 · source: Pa policy