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