Pennsylvania Medicaid coverage for Wegovy (Heart Disease Risk Reduction)

What you need to qualify

• BMI of 27 or higher
• Prior trial of another GLP-1 medication (Ozempic)
• Prescribed by or in consultation with a specialist
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (optimized pharmacotherapy for established cardiovascular disease per current consensus guidelines)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of specialist prescribing or consultation (cardiologist, vascular surgeon, or neurologist)
• Recent BMI documentation (>= 27 kg/m2)
• Documentation of qualifying CV event: prior MI, prior stroke, or PAD with claudication (ABI <0.85), revascularization history, or amputation due to atherosclerotic disease
• Documentation of current optimized pharmacotherapy for CVD per consensus guidelines, or reason it is contraindicated/not tolerated
• Documentation of therapeutic failure of Ozempic (semaglutide) at maximum FDA-approved dose, OR contraindication or intolerance to Ozempic (with chart documentation of troubleshooting attempts over at least 1 month if intolerance-based)
• For Wegovy 2.4 mg: documentation that dose titration to semaglutide 2 mg has been completed and medical reason supporting need for 2.4 mg dose — OR documentation of therapeutic failure of Ozempic at maximum dose
• Documentation of age-appropriateness per FDA labeling, compendia, or peer-reviewed literature
• Documentation of no contraindication to the prescribed drug
• If therapeutic duplication: documentation of intent to transition or medical reason for concomitant use supported by literature/guidelines

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for Renewal requires: (1) prescribed by or in consultation with appropriate specialist (cardiologist, vascular surgeon, neurologist); (2) used in combination with optimized pharmacotherapy for established CVD per current consensus guidelines unless contraindicated or not tolerated; (3) continued lifestyle changes and behavioral modifications; (4) no contraindication; (5) step-therapy requirement maintained (therapeutic failure/contraindication/intolerance to Ozempic max dose). BMI and qualifying CV event documentation not explicitly re-verified at renewal per renewal guidelines as stated, but specialist and GDMT requirements are re-checked.

Not covered when

• Overweight/obesity treatment indication excluded
• Saxenda (liraglutide) not covered for any indication

Policy note: Wegovy is non-preferred for all non-diabetes indications. For CV risk reduction, the step-therapy requirement is therapeutic failure of/contraindication to/intolerance to the maximum FDA-approved dose of Ozempic (semaglutide). PAD qualifying criteria are specific: requires at least one of intermittent claudication with ABI <0.85 at rest, history of peripheral arterial revascularization, or amputation due to atherosclerotic disease. For Wegovy 2.4 mg strength specifically, an alternative pathway exists: prior therapeutic failure of Ozempic at max dose OR (completed titration to semaglutide 2 mg plus medical reason for 2.4 mg). All non-OSA/non-MASH non-diabetes indications require a recent 6-month trial of lifestyle changes and behavioral modifications OR medical reason why immediate treatment is necessary at initial request. For CV and MASH, lifestyle changes are required but the 6-month prior trial requirement does not apply — concurrent lifestyle modification suffices. Prescriptions limited to 1-month supply per fill. Approval duration up to 6 months for non-diabetes, non-OSA indications.

Policy effective January 1, 2026 · verified June 4, 2026 · source: mab2025112403.pdf