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Oregon Medicaid

Does Oregon Medicaid cover Wegovy?

No. Oregon Medicaid's policies on file exclude Wegovy for weight loss on Medicaid plans.

Policy document

  • Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026

    Oregon Medicaid · PA policy · Medicaid

    Effective March 1, 2026. Verified June 4, 2026.

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  • Medicaid: Not covered. Document explicitly states: 'Semaglutide is not currently covered for adults who do not have established ca...

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.

Not covered

Document explicitly states: 'Semaglutide is not currently covered for adults who do not have established cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), or type 2 diabetes.' Additionally: 'Note: Drugs prescribed for weight management (e.g., obesity or overweight) in the absence of another evidence-supported indication are not currently covered.' Drugs prescribed for only weight management (overweight or obesity) are NOT currently covered per Table 3 note.

Policy note: Wegovy (semaglutide injection) is explicitly not covered for adults when indicated solely for weight loss/obesity/overweight without an evidence-supported indication such as established CV disease or MASH. This applies to the Oregon Health Plan (Oregon Medicaid). Note: pediatric weight loss (EPSDT) coverage via Wegovy injection is potentially available for children 12 years and older under the EPSDT pathway described in the approval criteria, but the document does not establish separate formal criteria for Wegovy specifically in this pediatric context (the EPSDT pathway covers FDA-approved drugs for weight management generally). The explicit adult exclusion is clear.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026 · View policy document (PDF)

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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.

CV Risk Reduction — Established Cardiovascular Disease

All of:

  • Established cardiovascular disease (history of myocardial infarction, stroke, or symptomatic peripheral arterial disease)
  • Prior weight loss treatment plan administered by a health care provider (e.g., diet and exercise program, nutritional counseling, and/or calorie restricted diet) for at least 3 months within the previous 6 months
  • Patient will be engaged in a weight management lifestyle modification program in addition to pharmacotherapy
  • Patient has been screened for diabetes within the past year with results indicating no diabetes (HbA1c <6.5% or fasting blood glucose <126 mg/dL) OR has a documented type 2 diabetes diagnosis

Documentation to bring

  • ICD-10 diagnosis code for the condition being treated
  • Documentation of established cardiovascular disease (e.g., history of MI, stroke, or symptomatic peripheral arterial disease)
  • Documentation of prior weight loss treatment plan administered by a health care provider for at least 3 months within the previous 6-month timeframe
  • Documentation of type 2 diabetes diagnosis OR diabetes screening results within the past year (HbA1c <6.5% or fasting blood glucose <126 mg/dL)
  • Attestation that patient will be engaged in a weight management lifestyle modification program

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • Renewal: At least 5% reduction in BMI.
  • Renewal: At renewal: patient must have lost or maintained a BMI reduction of 5% or more, been adherent to therapy per provider attestation, and be continuing with a weight loss treatment plan (diet/exercise, nutritional counseling, and/or calorie restricted diet). The diabetes screening/diagnosis check and T2DM exclusion from initial approval are not re-verified at renewal.

Policy note: Document states: 'Semaglutide is not currently covered for adults who do not have established cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), or type 2 diabetes.' Semaglutide (tablets or injection) is listed for the CV indication in Table 3. At renewal step 5, the renewal pathway for CV disease requires BMI reduction of 5% or more, adherence, and continuation of a weight loss treatment plan. Ozempic/Rybelsus are handled under a separate GLP-1 PA criteria document for T2DM and are not covered under this document.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026 · View policy document (PDF)

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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.

MASH — Liver Biopsy Confirmation

All of:

  • Patient is 18 years of age or older
  • Diagnosis of MASH confirmed by liver biopsy
  • Fibrosis stage 2 or 3 as shown by liver biopsy within the past 24 months
  • Medication ordered by, or in consultation with, a hepatologist or gastroenterologist

MASH — Non-Biopsy Clinical Confirmation

All of:

  • Patient is 18 years of age or older
  • Documentation that patient does NOT have ongoing or recent (within 2 years) significant alcohol use or chronic/active viral hepatitis (significant alcohol use defined as >21 drinks/week or >30 g/day in men; >14 drinks/week or >20 g/day in women)
  • Provider attestation or documentation that other causes of hepatic steatosis are not suspected or have been ruled out (e.g., Wilson's disease, lipodystrophy, abetalipoproteinemia, medications such as amiodarone, methotrexate, tamoxifen, corticosteroids)
  • Documentation that patient has, or is receiving drug treatment for, at least 3 of the 5 metabolic risk factors (overweight/obesity/increased waist circumference [BMI ≥25 kg/m2 or ethnicity-adjusted equivalent], hypertension, type 2 diabetes mellitus, hypertriglyceridemia, decreased HDL)
  • Fibrosis stage 2 or 3 as shown by appropriate diagnostic test within the past 24 months (biopsy, VCTE, MRE, or ELF)
  • Medication ordered by, or in consultation with, a hepatologist or gastroenterologist

Documentation to bring

  • ICD-10 diagnosis code for MASH
  • Patient age 18 years or older
  • Liver biopsy confirming MASH with fibrosis stage 2 or 3 (within past 24 months) OR all of: (1) documentation of absence of significant alcohol use (within 2 years) and no chronic/active viral hepatitis; (2) provider attestation ruling out other causes of hepatic steatosis; (3) documentation of at least 3 of 5 metabolic risk factors; (4) fibrosis staging test (VCTE, MRE, ELF, or biopsy) within past 24 months showing stage 2 or 3
  • Order or consultation note from a hepatologist or gastroenterologist

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • Renewal: At renewal: provider must attest to patient adherence (or adherence apparent from claims history); patient must have had a complete metabolic panel, liver enzymes, or other appropriate biochemical or noninvasive imaging test within the past 12 months to assess disease progression (examples: FIB-4, ELF, VCTE, MRE); if semaglutide initiation was more than 3 years ago, noninvasive imaging (VCTE or MRE) or repeat liver biopsy must have been done within the past 3 years; patient must NOT have evidence of stage F4 fibrosis (cirrhosis) or worsened fibrosis stage since starting semaglutide; documentation of a risk/benefit assessment for ongoing treatment with semaglutide with possible resolution of metabolic comorbidities must be present. If adherence is not confirmed, approve once for 3 months. If monitoring tests are missing, approve once for 3 months. If imaging/biopsy update is missing (>3 years), approve once for 3 months. If risk/benefit assessment is missing, approve once for 3 months.

Not covered when

  • Fibrosis stage F4 (cirrhosis) — triggers denial at renewal
  • Worsening fibrosis stage since starting semaglutide — triggers denial at renewal
  • Active or recent (within 2 years) significant alcohol use
  • Chronic or active viral hepatitis

Policy note: Injection only for MASH indication. Alcohol limit defined as >30 g/day (>21 drinks/week) for men and >20 g/day (>14 drinks/week) for women. The 24-month lookback applies to all fibrosis staging methods listed (biopsy, VCTE, MRE, ELF). At renewal, if semaglutide was initiated more than 3 years ago, a repeat imaging or biopsy within the past 3 years is required. The MASH pathway bypasses the standard BMI and lifestyle program requirements (approval criteria flow goes directly to #14 for MASH). The document also notes liraglutide (Saxenda) is covered for MASH with stage 2 or 3 fibrosis in adults ≥18 years, but liraglutide is not in the in-scope list.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026 · View policy document (PDF)

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If weight loss isn't covered on your plan

Oregon Medicaid has separate Wegovy policies that don't depend on that benefit:

Questions people ask
Does Oregon Medicaid cover Wegovy?
No. Oregon Medicaid's policies on file exclude Wegovy for weight loss on Medicaid plans.
How long does a Wegovy approval last with Oregon Medicaid?
Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 12 months. Liver Disease (MASH) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 12 months.
What does Oregon Medicaid require to renew Wegovy?
Heart Disease Risk Reduction — Applies to Medicaid plans. At least 5% reduction in BMI. At renewal: patient must have lost or maintained a BMI reduction of 5% or more, been adherent to therapy per provider attestation, and be continuing with a weight loss treatment plan (diet/exercise, nutritional counseling, and/or calorie restricted diet). The diabetes screening/diagnosis check and T2DM exclusion from initial approval are not re-verified at renewal. Liver Disease (MASH) — Applies to Medicaid plans. At renewal: provider must attest to patient adherence (or adherence apparent from claims history); patient must have had a complete metabolic panel, liver enzymes, or other appropriate biochemical or noninvasive imaging test within the past 12 months to assess disease progression (examples: FIB-4, ELF, VCTE, MRE); if semaglutide initiation was more than 3 years ago, noninvasive imaging (VCTE or MRE) or repeat liver biopsy must have been done within the past 3 years; patient must NOT have evidence of stage F4 fibrosis (cirrhosis) or worsened fibrosis stage since starting semaglutide; documentation of a risk/benefit assessment for ongoing treatment with semaglutide with possible resolution of metabolic comorbidities must be present. If adherence is not confirmed, approve once for 3 months. If monitoring tests are missing, approve once for 3 months. If imaging/biopsy update is missing (>3 years), approve once for 3 months. If risk/benefit assessment is missing, approve once for 3 months.
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 Oregon Medicaid: Mounjaro, Ozempic, Zepbound

Wegovy under other plans: Kaiser Permanente Northwest, PacificSource Health, Regence, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid

All insurance plans · All medications

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