Virginia Medicaid coverage for Wegovy (Weight Loss)

No additional clinical requirements are listed beyond the diagnosis.

Documentation to bring

• Weight Management Agents SA Form

Policy note: Wegovy is listed as a Non-Preferred agent under the Weight Management Agents CLOSED CLASS. The SA criteria reference a 'Weight Management Agents SA Form' for full clinical criteria details, which are not reproduced in this document. The document also references separate SA forms for CV risk reduction, OSA, and MASH indications. Authorization length is 'as indicated on fax form'.

Policy effective April 1, 2026 · verified June 4, 2026 · source: VAmed-PDL-List-Criteria-20260401-v6.pdf