Medicaid
Covered (preferred drug)What you need to qualify
- Age 18 and older
- BMI of 27 or higher
- Established cardiovascular disease (MI, stroke, and PAD)
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
- To renew, the plan looks for at least 5% weight loss from the starting weight and Adults (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy. Make sure your starting weight and date are in the chart now — renewal is measured against it.
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.pdf