Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
- 3 months of a documented diet and exercise program
- Established cardiovascular disease (MI, stroke, and PAD)
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
- To renew, the plan looks for at least 5% reduction in BMI and 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%20Medicaid%20PA%20Criteria%20Guide%20-%20June%201%2C%202026.pdf