Washington Medicaid

Does Washington Medicaid cover Wegovy?

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Quick answer · Weight Loss

Washington Medicaid does not cover it for weight loss on Medicaid.

  • Medicaid: Not covered. Semaglutide injection or tablet (Wegovy) is not covered by Apple Health for weight loss in accordance with WAC 182-530-2100(1)(b)(i) and SEC. 1927 [42 U.S.C. 1396r-8](d)(2)(A).

Last verified June 4, 2026. Policy effective February 1, 2026. Source: semaglutide.pdf. How we verify this data →

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Wegovy for Weight Loss

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

Medicaid

Not covered

Semaglutide injection or tablet (Wegovy) is not covered by Apple Health for weight loss in accordance with WAC 182-530-2100(1)(b)(i) and SEC. 1927 [42 U.S.C. 1396r-8](d)(2)(A).

Policy note: Weight loss is explicitly non-covered under Apple Health (Washington Medicaid) per state regulation WAC 182-530-2100(1)(b)(i) and federal statute 42 U.S.C. 1396r-8(d)(2)(A), which excludes agents used for weight gain or loss from Medicaid coverage. Both injection and tablet formulations are excluded for this indication.

Policy effective February 1, 2026 · verified June 4, 2026 · source: semaglutide.pdf

Wegovy for Heart Disease Risk Reduction

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • A1C no higher than 6.5%
  • Established cardiovascular disease (prior_stroke_ischemic, prior_stroke_hemorrhagic, prior_MI, symptomatic_carotid_artery_disease, symptomatic_coronary_artery_disease, and symptomatic_PAD)
  • On guideline-directed medical therapy (antiplatelet_therapy, antihypertensive_therapy, and lipid_lowering_therapy)
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial approval: CV risk reduction in overweight/obesity without diabetes

All of:

  • BMI >= 27 kg/m2
  • Age >= 18 years
  • No diabetes and A1C <= 6.5% (patients with T2DM or A1C >6.5 referred to GLP-1 diabetes policy 27.17.00)
  • Established cardiovascular disease with at least one qualifying event
  • Concurrent use of at least one secondary prevention medication (antiplatelet, antihypertensive, or lipid-lowering therapy) unless contraindicated or not tolerated
  • Semaglutide will not be used in combination with another GLP-1 receptor agonist or DPP4 inhibitor

Plus any one of:

  • Prior ischemic or hemorrhagic stroke
  • Prior myocardial infarction (MI)
  • Symptomatic carotid artery disease (moderate-severe stenosis >50%, revascularization of internal carotid artery, or TIA with focal neurological dysfunction or transient monocular blindness)
  • Symptomatic coronary artery disease (coronary stenosis >=50%, symptomatic angina pectoris, or prior coronary revascularization)
  • Symptomatic peripheral arterial disease (intermittent claudication with ABI <0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease)

Reauthorization: CV risk reduction

All of:

  • Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
  • Patient continues to meet initial criteria 2-6 (age, no T2DM/A1C >6.5%, established CV disease, concurrent secondary prevention medication, no GLP-1/DPP4 combination)

Documentation to bring

  • Baseline BMI documentation (>= 27 kg/m2)
  • Documentation confirming no diabetes diagnosis and A1C <= 6.5%
  • Documentation of qualifying established CV event (prior stroke, MI, symptomatic carotid artery disease, symptomatic CAD, or symptomatic PAD with supporting evidence)
  • Documentation of concurrent secondary prevention medication use (antiplatelet, antihypertensive, or lipid-lowering therapy) OR documented contraindication/intolerance to all three classes
  • Confirmation that semaglutide will not be used with another GLP-1 receptor agonist or DPP4 inhibitor

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL, 1.7 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Initial PA
  • 2.4 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Renewal PA
  • 1.5 mg tablet, 4 mg tablet, 9 mg tablet, 25 mg tablet — 1 tablet per day

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for Patient must continue to meet criteria 2-6 from initial approval (age >=18, no T2DM/A1C >6.5%, established CV disease, concurrent secondary prevention medication, no combination with GLP-1 or DPP4 inhibitor). Note: BMI criterion (>=27) is explicitly NOT re-checked at reauthorization per version AA-2 change history.

Not covered when

  • Patients with T2DM or A1C > 6.5% are excluded (referred to GLP-1 diabetes policy 27.17.00)
  • Concurrent use with another GLP-1 receptor agonist is excluded
  • Concurrent use with a DPP4 inhibitor is excluded

Policy note: This is an Apple Health (Washington State Medicaid) policy. The policy explicitly references WAC 182-530-2100 and other state regulatory authority. Qualifying CV events include detailed sub-criteria: carotid artery stenosis requires occlusion >50% or revascularization or TIA with focal deficits; CAD requires stenosis >=50% or symptomatic angina or revascularization; PAD requires claudication with ABI <0.85 or revascularization or amputation due to atherosclerotic disease. GDMT requirement allows any ONE of three medication classes (antiplatelet, antihypertensive, lipid-lowering) unless all are contraindicated or not tolerated. Per version history (AA-3, effective 12/1/2025), lifestyle requirements were removed. Per version history (AA-2, effective 5/1/2025), reauthorization no longer requires re-verification of BMI. Wegovy tablet (oral semaglutide) added in version AA-4 (effective 2/1/2026) — tablet formulation only applies to CV risk reduction indication, not MASH.

Policy effective February 1, 2026 · verified June 4, 2026 · source: semaglutide.pdf

Wegovy for Liver Disease (MASH)

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • A1C no higher than 6.5%
  • Confirmed MASH diagnosis by liver_biopsy, FIB-4, FibroScan_VCTE, APRI, Fibrotest, and Elastography_ARFI_PSWE, fibrosis stage F2 to F3
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial approval: Moderate to severe noncirrhotic MASH (F2-F3) without diabetes

All of:

  • Age >= 18 years
  • No diabetes and A1C <= 6.5% (patients with T2DM or A1C >6.5 referred to GLP-1 diabetes policy 27.17.00)
  • Diagnosis of moderate to severe MASH (fibrosis stage F2 or F3) confirmed by at least one listed method
  • At least one cardiovascular risk factor from Appendix A (CKD, dyslipidemia, hypertension, obesity BMI >=30, or prediabetes)

Plus any one of:

  • Liver biopsy confirming F2-F3 fibrosis
  • FIB-4 score 1.3 to 3.48
  • FibroScan score 8.5 to 13.5 kPa
  • APRI score 1.0 to 1.9
  • Fibrotest score 0.49 to 0.74
  • Elastography (ARFI/PSWE) 1.38 to 2.33 m/s

Reauthorization: MASH

All of:

  • Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
  • Patient continues to meet initial criteria 1-4 (age, no T2DM/A1C >6.5%, MASH F2-F3 confirmation, CV risk factor)
  • Patient does not have cirrhosis (fibrosis score must not be >F3)

Documentation to bring

  • Documentation confirming no diabetes diagnosis and A1C <= 6.5%
  • Diagnosis of moderate to severe noncirrhotic MASH (F2 or F3) confirmed by one of: liver biopsy, FIB-4 score 1.3-3.48, FibroScan 8.5-13.5 kPa, APRI 1.0-1.9, Fibrotest 0.49-0.74, or Elastography (ARFI/PSWE) 1.38-2.33 m/s
  • Documentation of at least one cardiovascular risk factor (CKD, dyslipidemia, hypertension, obesity BMI >=30, or prediabetes)

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL, 1.7 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Initial PA
  • 2.4 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Renewal PA

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for Patient must continue to meet initial criteria 1-4 (age >=18, no T2DM/A1C >6.5%, MASH F2-F3 diagnosis confirmed, at least one cardiovascular risk factor) AND patient must not have cirrhosis (fibrosis score must not be >F3). Noncirrhotic status re-verified at reauthorization.

Not covered when

  • Patients with T2DM or A1C > 6.5% are excluded (referred to GLP-1 diabetes policy 27.17.00)
  • Cirrhosis (fibrosis stage >F3) is an exclusion at reauthorization
  • Only injectable formulation (not tablet) covered for MASH indication

Policy note: MASH indication covers only Wegovy injection, not the Wegovy tablet. The policy title spells 'nonalchoholic' (sic). Fibrosis staging is limited to noncirrhotic disease (F2-F3); cirrhosis (>F3) is an explicit exclusion at reauthorization. Cardiovascular risk factors from Appendix A are listed as 'including but not limited to': CKD, dyslipidemia, hypertension, obesity (BMI >=30), and prediabetes. No lookback periods are specified for any confirmation method. Specific score ranges are provided for each non-biopsy confirmation method mapping to F2-F3 disease.

Policy effective February 1, 2026 · verified June 4, 2026 · source: semaglutide.pdf

Why Wegovy requests get denied by Washington Medicaid

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

  1. Your plan's benefit excludes weight loss medications. A prior authorization cannot override a benefit exclusion — ask about a formulary exception or a different covered pathway.
  2. 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.
  3. BMI not documented in the chart notes (or documented without a baseline weight and date).

If weight loss isn't covered on your plan

Washington Medicaid has separate Wegovy policies that don't depend on the weight loss benefit:

Wegovy is also sold directly by Novo Nordisk without insurance through NovoCare.

Frequently asked questions

Does Washington Medicaid cover Wegovy?
Washington Medicaid does not cover it for weight loss on Medicaid.
How long does a Wegovy approval last with Washington Medicaid?
Initial approvals last 6 months, and renewals are granted in 12-month periods.
What does Washington Medicaid require to renew Wegovy?
Patient must continue to meet criteria 2-6 from initial approval (age >=18, no T2DM/A1C >6.5%, established CV disease, concurrent secondary prevention medication, no combination with GLP-1 or DPP4 inhibitor). Note: BMI criterion (>=27) is explicitly NOT re-checked at reauthorization per version AA-2 change history.
What if my plan excludes weight loss medications?
Washington Medicaid has separate Wegovy policies for heart disease risk reduction and liver disease (mash), which are covered on some plan types and don't depend on the weight-loss benefit. Wegovy is also available for cash through NovoCare.
How current is this information?
This page reflects Washington Medicaid's written policy as of February 1, 2026, last verified against the source document on June 4, 2026.

Other medications under Washington Medicaid

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Washington 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.