Tennessee Medicaid

Does Tennessee Medicaid cover Wegovy?

Quick answer · Weight Loss

Tennessee Medicaid covers Wegovy for weight loss with prior authorization on Medicaid.

  • Medicaid: Covered (preferred drug). BMI of 30 or higher

Last verified June 3, 2026. Policy effective June 1, 2026. Source: Criteria-PDL.pdf. How we verify this data →

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Wegovy for Weight Loss

What Tennessee Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered (preferred drug)

What you need to qualify

  • Age 12 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (HTN, dyslipidemia, T2DM, coronary_heart_disease, MASH, and OSA)
  • BMI at or above the 95th percentile for age and sex
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Initial Approval — Pediatric (< 18 years)

All of:

  • Age >= 12 years
  • Treatment is for management of obesity
  • BMI >= 95th percentile standardized for age and sex (documented via medical records/chart notes)
  • Prescriber attests patient is participating in complementary nutritional and lifestyle changes
  • Medication will not be used in combination with other FDA-approved obesity/weight loss medications
  • Will not be co-administered with another GLP-1 receptor agonist
  • No personal or immediate family history of medullary thyroid carcinoma or MEN2

Initial Approval — Adult (>= 18 years), BMI > 30

All of:

  • Age >= 18 years
  • Treatment is for management of obesity
  • BMI > 30 kg/m² (documented via medical records/chart notes)
  • Prescriber attests patient is participating in complementary nutritional and lifestyle changes
  • Medication will not be used in combination with other FDA-approved obesity/weight loss medications
  • Will not be co-administered with another GLP-1 receptor agonist
  • No personal or immediate family history of medullary thyroid carcinoma or MEN2

Initial Approval — Adult (>= 18 years), BMI > 27 with comorbidity

All of:

  • Age >= 18 years
  • Treatment is for management of obesity
  • BMI > 27 kg/m² (documented via medical records/chart notes)
  • Prescriber attests patient is participating in complementary nutritional and lifestyle changes
  • Medication will not be used in combination with other FDA-approved obesity/weight loss medications
  • Will not be co-administered with another GLP-1 receptor agonist
  • No personal or immediate family history of medullary thyroid carcinoma or MEN2

Plus any one of:

  • Hypertension
  • Dyslipidemia
  • Diabetes
  • Coronary heart disease
  • MASH/NASH
  • Obstructive sleep apnea

Renewal

All of:

  • Continued participation in complementary nutritional and lifestyle changes
  • Medication will not be used in combination with other obesity/weight loss medications
  • Documentation of >= 5% weight loss from baseline body weight

Documentation to bring

  • Medical records (e.g., chart notes) documenting BMI >= 95th percentile for age and sex (patients < 18 years)
  • Medical records (e.g., chart notes) documenting BMI > 30 kg/m² (adults >= 18 years, BMI-only pathway)
  • Medical records (e.g., chart notes) documenting BMI > 27 kg/m² with a weight-related comorbidity (adults >= 18 years, comorbidity pathway)
  • Prescriber attestation that patient is participating in complementary nutritional and lifestyle changes
  • At renewal: medical records (e.g., chart notes) documenting weight loss of >= 5% of baseline body weight

Quantity limits

  • all strengths — 4 injections/month

Approval and renewal

  • To renew, the plan looks for at least 5% weight loss from the starting weight and Documentation of >= 5% weight loss from baseline body weight. Continued participation in complementary nutritional and lifestyle changes required. Patients not meeting renewal criteria may be approved for up to one month to allow for titration off medication. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Personal or immediate family history of medullary thyroid carcinoma (MTC)
  • Personal or immediate family history of multiple endocrine neoplasia type 2 (MEN2)
  • Concurrent use of other FDA-approved obesity/weight loss medications
  • Concurrent use of another GLP-1 receptor agonist

Policy note: PDL Status: Preferred (P). Document is TennCare PDL (Tennessee Medicaid). Patients not meeting renewal criteria may be approved for up to one month to allow for titration off medication. The lifestyle program attestation is required (prescriber-attested participation), not merely FDA label language — set requires_lifestyle_program: true. The document does not specify separate quantity limits by dose strength; a single limit of 4 injections/month applies to all strengths.

Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf

Wegovy for Heart Disease Risk Reduction

What Tennessee Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered (preferred drug)

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • 6 months of a documented diet and exercise program
  • Established cardiovascular disease (MI, stroke, and PAD)
  • On guideline-directed medical therapy (beta_blocker, RAS_inhibitor, and lipid_lowering_agent)

Qualification pathways

You can qualify through any one of these.

Initial approval for CV Risk Reduction

All of:

  • Treatment requested to reduce risk of major adverse cardiovascular events
  • Patient is 18 years of age or older
  • Initial BMI >= 27 kg/m2 documented in medical records
  • Patient is on optimized guideline-directed therapy including beta-blockers, RAS inhibitors, and lipid-lowering agents unless contraindicated
  • Prescriber attests patient is participating in complementary nutritional and lifestyle changes
  • Will not be used concomitantly with DPP-4 inhibitors
  • Will not be co-administered with another GLP-1 receptor agonist

Plus any one of:

  • Prior myocardial infarction
  • Prior stroke (ischemic and hemorrhagic)
  • Symptomatic peripheral arterial disease as evidenced by intermittent claudication with ankle brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

Documentation to bring

  • Medical documentation (e.g., chart notes) of initial BMI >= 27 kg/m2
  • Medical documentation of qualifying CVD event: prior MI, prior stroke, or symptomatic PAD (intermittent claudication with ABI < 0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
  • Documentation of current optimized GDMT use (beta-blockers, RAS inhibitors, lipid-lowering agents) or claims history, unless contraindicated
  • Prescriber attestation that patient is participating in complementary nutritional and lifestyle changes

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — 4 injectors

Approval and renewal

  • To renew, the plan looks for Positive clinical response required: patient has not had a major cardiovascular event within the past 12 months, OR decreased body weight or waist circumference from baseline, OR decreased blood pressure, total cholesterol, LDL, or triglyceride levels from baseline. GDMT requirement IS re-verified at renewal. Lifestyle attestation IS re-verified at renewal. DPP-4 inhibitor exclusion and GLP-1 co-administration exclusion re-verified at renewal.

Not covered when

  • Concomitant use of DPP-4 inhibitors
  • Co-administration with another GLP-1 receptor agonist (e.g., Byetta, Ozempic, Victoza)

Policy note: Qualifying PAD criteria include: intermittent claudication with ABI < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. GDMT must include beta-blockers, RAS inhibitors, and lipid-lowering agents unless contraindicated, supported by medical documentation or claims history. The document does not explicitly exclude patients with diabetes from this indication. Quantity limit is 4 injectors per 28 days.

Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf

Wegovy for Liver Disease (MASH)

What Tennessee Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered (preferred drug)

What you need to qualify

  • Age 18 and older
  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by FibroScan_VCTE, FIB-4, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Initial approval for NASH/MASH

All of:

  • Patient is 18 years of age or older
  • Diagnosis of NASH or MASH
  • Fibrosis stage F2 or F3 confirmed by an approved diagnostic method
  • Prescriber attests patient is participating in a supervised comprehensive weight management program
  • Prescribed by or in consultation with a gastroenterologist or hepatologist
  • Will not be used concomitantly with DPP-4 inhibitors
  • Will not be co-administered with another GLP-1 receptor agonist
  • No personal or immediate family history of medullary thyroid carcinoma or MEN2

Plus any one of:

  • Fibrosis confirmed by FibroScan
  • Fibrosis confirmed by Fibrosis-4 index (FIB-4)
  • Fibrosis confirmed by Magnetic Resonance Elastography (MRE)
  • Fibrosis confirmed by liver biopsy

Documentation to bring

  • Medical records (e.g., chart notes) confirming diagnosis of NASH or MASH
  • Medical records confirming fibrosis stage F2 or F3 via FibroScan, FIB-4, MRE, or liver biopsy
  • Prescriber attestation that patient is participating in a supervised comprehensive weight management program
  • Documentation of prescriber specialty (gastroenterologist or hepatologist) or consultation note
  • Documentation that patient has no personal or immediate family history of medullary thyroid carcinoma or MEN2

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — 4 injectors

Approval and renewal

  • To renew, the plan looks for Positive clinical response required: improvement in NASH/MASH disease symptoms documented in recent medical records (chart notes and/or labs).

Not covered when

  • Personal or immediate family history of medullary thyroid carcinoma or MEN2
  • Concomitant use of DPP-4 inhibitors
  • Co-administration with another GLP-1 receptor agonist

Policy note: Document uses both NASH and MASH terminology interchangeably. Fibrosis stage must be F2 or F3 (not F1, F4, or cirrhotic). No specific lookback periods stated for diagnostic tests. Specialist requirement: prescribed by or in consultation with a gastroenterologist or hepatologist. Renewal only requires positive clinical response documentation; specialist, BMI, and fibrosis confirmation requirements are not explicitly re-verified at renewal.

Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf

Why Wegovy requests get denied by Tennessee Medicaid

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Wegovy and Ozempic are the same molecule with different approved uses; a request for Wegovy under a diagnosis that matches Ozempic is routinely denied.
  2. BMI not documented in the chart notes (or documented without a baseline weight and date).
  3. Qualifying weight-related condition not documented with its own diagnosis code.
  4. No documented diet and exercise program.
  5. Prescriber isn't the specialist the plan requires.
  6. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Tennessee Medicaid cover Wegovy?
Tennessee Medicaid covers Wegovy for weight loss with prior authorization on Medicaid.
What BMI do you need for Wegovy under Tennessee Medicaid?
For weight loss on Medicaid plans, Tennessee Medicaid requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.
What does Tennessee Medicaid require to renew Wegovy?
At least 5% weight loss from the starting weight and Documentation of >= 5% weight loss from baseline body weight. Continued participation in complementary nutritional and lifestyle changes required. Patients not meeting renewal criteria may be approved for up to one month to allow for titration off medication.
How current is this information?
This page reflects Tennessee Medicaid's written policy as of June 1, 2026, last verified against the source document on June 3, 2026.

Other medications under Tennessee Medicaid

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Tennessee Medicaid's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.