Medicaid
Covered with requirementsWhat you need to qualify
- Age 45 and older
- BMI of 27 or higher
- A1C no higher than 6.5%
- Established cardiovascular disease (MI, stroke, and PAD)
- On guideline-directed medical therapy (antihypertensives, lipid-lowering agents, and antiplatelets)
- Lab results confirming eligibility
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction โ initial approval
All of:
- FDA approved indication to reduce risk of major adverse CV events
- Member is 45 years of age or older
- BMI >= 27 kg/m2
- Established CVD with history of qualifying event
- HbA1c < 6.5% (no T1DM or T2DM)
- Not using Wegovy in combination with other semaglutide-containing products or any GLP-1 receptor agonist
- Currently receiving GDMT for CVD (antihypertensives, lipid-lowering agents, antiplatelets) as documented in pharmacy claims history, unless contraindicated
- Diet and exercise used in conjunction (clinical documentation required)
Plus any one of:
- Previous myocardial infarction
- Previous stroke
- Symptomatic peripheral arterial disease confirmed by intermittent claudication with ankle-brachial index <0.85 at rest, OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease
Documentation to bring
- Documentation of established CVD with qualifying event (previous MI, previous stroke, or symptomatic PAD confirmed by ABI <0.85, revascularization, or amputation due to atherosclerotic disease)
- Baseline BMI >= 27 kg/m2
- HbA1c lab result confirming < 6.5%
- Documentation of current GDMT use (antihypertensives, lipid-lowering agents, antiplatelets) via pharmacy claims history, or documentation of contraindication
- Clinical documentation (e.g., office notes) of diet and exercise discussion with member
- Confirmation member will not use Wegovy in combination with other semaglutide-containing products or any GLP-1 receptor agonist
Quantity limits
- all injection strengths โ 4 pens per 28 days
- 25mg tablets โ 30 tablets per 30 days
Approval and renewal
- Initial approval: 2 months
- Renewal: every 12 months
- To renew, the plan looks for Member is tolerating maintenance dosing; member has not developed T1DM or T2DM; member is continuing reduced calorie diet, increased physical activity, and GDMT for CVD where applicable. Note: BMI threshold, established CVD documentation, and age requirement are not explicitly re-verified at continuation per the document and staying on a maintenance dose of at least 1.7 mg.
Not covered when
- Type 2 diabetes mellitus (T2DM excluded; HbA1c must be <6.5%)
- Concurrent use with other semaglutide-containing products or any GLP-1 receptor agonist
- Obese or overweight members without established CVD will not be approved
- Members who cannot tolerate dose escalation after additional 8-week approval will not be approved for continuation
- Wegovy should be discontinued if member cannot tolerate at least 1.7mg once weekly maintenance dosing
- Type 1 diabetes
Policy note: Initial approvals are for 8-week titration periods per dose; a separate PA must be submitted for each dose. An additional 8 weeks per dose may be approved for intolerable adverse effects during escalation with documentation. Subsequent (maintenance) approvals are for 1 year. Qualifying PAD events include intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease. Both injection and tablet formulations (25mg) are addressed. Wegovy tablets (oral semaglutide) are included in the CV risk reduction criteria in this document. Last modified date on the Metabolic Disorders page is April 24, 2026.
verified June 4, 2026 ยท source: policy-385.html