Washington Medicaid coverage for Wegovy (Heart

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

Washington Medicaid coverage for Wegovy (Heart Disease Risk Reduction)