West Virginia Medicaid coverage for Wegovy (Heart

Medicaid

Covered with requirements

What you need to qualify

BMI of 27 or higher
A1C no higher than 6.5%
Prescribed by or in consultation with a specialist
Established cardiovascular disease (MI, stroke, and PAD)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction — Initial Approval

All of:

Patient is within the FDA-label recommended age range
BMI >= 27 kg/m2 (date and results of most recent BMI calculation stated on request)
Prescribed by or in consultation with an M.D./D.O. or specialty trained prescriber with clinical specialty certification/degree in cardiology, vascular surgery, or neurology
Patient attests to behavioral modification including a reduced calorie diet and increased physical activity
HbA1c level taken within the last 6 months is provided
HbA1c <= 6.5%
Patient does NOT have type 1 or type 2 diabetes
Medication will not be used with other GLP-1 agonist agents

Plus any one of:

Prior myocardial infarction
Prior stroke
Symptomatic peripheral arterial disease (PAD) demonstrated by: formal vascular laboratory testing showing intermittent claudication with ABI <= 0.85 at rest, OR peripheral revascularization procedure, OR amputation due to atherosclerotic disease

Documentation to bring

Documentation of BMI >= 27 kg/m2 with date and results of most recent BMI calculation
Prescription by or documentation of consultation with M.D./D.O. or specialist in cardiology, vascular surgery, or neurology
Documentation of qualifying CV event: prior MI, prior stroke, or symptomatic PAD (with supporting vascular lab results showing ABI <= 0.85, or evidence of peripheral revascularization or amputation due to atherosclerotic disease)
Patient attestation of behavioral modification including reduced calorie diet and increased physical activity
HbA1c lab result taken within the last 6 months
Confirmation that patient does not have type 1 or type 2 diabetes and HbA1c is <= 6.5%
Confirmation that medication will not be co-administered with other GLP-1 agonist agents

Approval and renewal

Initial approval: 3 months
Renewal: every 6 months
To renew, the plan looks for Patient continues to meet all initial approval criteria AND demonstrates continued documented compliance AND is taking an appropriate maintenance dose of 1.7 mg or 2.4 mg per week. If 1.7 mg dose is intolerable, medication should be discontinued. Initial approval criteria (including T2DM/T1DM exclusion and A1C <= 6.5%) are re-verified at continuation and staying on a maintenance dose of at least 1.7 mg.

Not covered when

Type 2 diabetes (excluded — HbA1c must be <= 6.5% and no T1DM or T2DM diagnosis)
Concomitant use with other GLP-1 agonist agents
Type 1 diabetes

Policy note: HbA1c > 6.5% is an exclusion criterion. Both type 1 and type 2 diabetes are explicitly excluded. Symptomatic PAD must be demonstrated by one of three specified methods: ABI <= 0.85 on formal vascular lab testing, peripheral revascularization procedure, or amputation due to atherosclerotic disease. Initial approval is 90 days; continuation approvals are 6 months. Prescriber must be an M.D./D.O. or specialty-certified in cardiology, vascular surgery, or neurology.

Policy effective January 1, 2026 · verified June 3, 2026 · source: download

West Virginia Medicaid coverage for Wegovy (Heart Disease Risk Reduction)