Applies to Medicaid plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Adult (age ≥ 18): CV risk reduction with BMI ≥ 27 and prior CV event
All of:
- Patient age ≥ 18 years
- Initial BMI ≥ 27 kg/m2
- Prescriber attests patient will not use more than one weight loss medication concurrently
- Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
- Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
- Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
- Prescriber attests medication is part of a total treatment plan including diet and exercise
- Prescriber attests patient has been informed weight may return with cessation of medication
Plus any one of:
- Prior myocardial infarction
- Prior stroke
- Peripheral arterial disease
Documentation to bring
- Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
- Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist (Wegovy, Saxenda, or Zepbound) concurrently with a DPP4 inhibitor
- Documentation of patient age ≥ 18 years
- Documentation of baseline BMI ≥ 27 kg/m2
- Documentation of qualifying prior cardiovascular event (prior MI, prior stroke, or peripheral arterial disease)
- If eating disorder present: prescriber attestation that treatment has been optimized and confirms safety and appropriateness
- Prescriber attestation that metabolic or other reasons for obesity have been ruled out or diagnosed and treated
- Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
- Prescriber attestation that medication is part of a total treatment plan including diet and exercise
- Prescriber attestation that patient has been informed weight may return with cessation of medication
- For renewal: clinical documentation of weight loss ≥ 5% from baseline
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- Renewal: Adults (≥18): documented weight loss of ≥5% from baseline weight at initiation of therapy.
Not covered when
- Lactation
- Personal or family history of medullary thyroid cancer
- Personal or family history of multiple endocrine neoplasia type II
- Concurrent use of more than one weight loss medication in this drug class
- Concurrent use with DPP4 inhibitor
- Pregnancy
Policy note: CV risk reduction pathway is carved out from the standard BMI-with-comorbidity pathway; listed as a distinct qualifying condition: 'This medication is being prescribed for cardiovascular risk reduction in members with prior myocardial infarction, prior stroke, or peripheral arterial disease (Wegovy)'. Duration of approval is 6 months for both initial and renewal.
Policy effective May 1, 2025 · verified June 10, 2026 · source: Medicaid Rx PA Criteria · View policy document (PDF)