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Wisconsin Medicaid

Does Wisconsin Medicaid cover Wegovy?

Yes. Wisconsin Medicaid covers Wegovy for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.

Policy document

  • Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review June 3, 2026. How we verify · Check your exact plan · Medicaid card names in Wisconsin

Full requirements: Wegovy for Weight Loss (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Pathway 1: BMI ≥ 30

All of:

  • Member is 12 years of age or older
  • BMI ≥ 30 (for ages 12-17: BMI ≥ 95th percentile standardized by age and gender)
  • Not pregnant or nursing
  • No history of eating disorder (anorexia, bulimia, binge eating disorder)
  • Prescriber evaluated and determined no medical or medication contraindications
  • Member has participated in a weight loss treatment plan in the past 6 months and will continue

Pathway 2: BMI 27-<30 with comorbidities

All of:

  • Member is 18 years of age or older
  • BMI ≥ 27 and < 30
  • Not pregnant or nursing
  • No history of eating disorder (anorexia, bulimia, binge eating disorder)
  • Prescriber evaluated and determined no medical or medication contraindications
  • Member has participated in a weight loss treatment plan in the past 6 months and will continue

Plus any one of:

  • Currently being treated for dyslipidemia AND at least one other qualifying risk factor
  • Currently being treated for hypertension AND at least one other qualifying risk factor
  • Currently being treated for sleep apnea AND at least one other qualifying risk factor
  • Currently being treated for type 2 diabetes mellitus AND at least one other qualifying risk factor
  • Has cardiovascular disease (history of MI, coronary revascularization, angina pectoris, stroke, intermittent claudication with ABI ≤ 0.9, peripheral arterial revascularization due to atherosclerotic disease, or amputation due to atherosclerotic disease) AND at least one other qualifying risk factor

Documentation to bring

  • Completed, signed, and dated Prior Authorization Drug Attachment for Anti-Obesity Drugs form (F-00163)
  • Documentation of member's current BMI
  • Documentation of qualifying comorbidities (if BMI 27-<30 pathway)
  • Documentation that member has participated in a weight loss treatment plan in the past 6 months
  • Prescriber attestation of no medical or medication contraindications
  • Confirmation member is not pregnant or nursing
  • Confirmation no history of eating disorder

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Member must achieve at least 5% weight loss from baseline. Member must be taking an appropriate maintenance dose as outlined in Wegovy prescribing information. PA will not be renewed if BMI falls below 24. Maximum treatment period is 12 continuous months; after that, member must wait 6 months before requesting again. ForwardHealth allows only two lifetime weight loss attempts with Wegovy.

Not covered when

  • Nursing (breastfeeding)
  • History of eating disorder (anorexia, bulimia, binge eating disorder)
  • Medical or medication contraindications as determined by prescriber
  • OTC anti-obesity drugs not covered
  • BMI below 24 at renewal — PA will not be renewed
  • Only one anti-obesity drug covered per member at a time
  • Maximum of two lifetime weight loss attempts with Wegovy
  • After 12 months of continuous treatment, must wait 6 months before requesting again
  • Pregnancy

Policy note: ForwardHealth (Wisconsin Medicaid). Dual eligibles enrolled in Medicare Part D PDP are covered for anti-obesity drugs. For members aged 12-17, BMI must be ≥ 95th percentile standardized by age and gender. The BMI 27-<30 pathway requires two or more qualifying risk factors. PA will not be renewed if member's BMI is below 24. ForwardHealth covers only one anti-obesity drug per member. Allows only two lifetime weight loss attempts with Wegovy.

verified June 3, 2026 · source: Wisconsin Medicaid Medicaid prior authorization policy · View policy document (PDF)

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Full requirements: Wegovy for Heart Disease Risk Reduction (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction — Established CVD with overweight/obesity

All of:

  • Wegovy prescribed consistent with FDA-approved labeling
  • BMI ≥ 27
  • Member agrees to follow reduced-calorie diet and increase physical activity

Plus any one of:

  • Prior myocardial infarction (heart attack)
  • Prior stroke
  • Peripheral arterial disease evidenced by intermittent claudication with ABI ≤ 0.9
  • Peripheral arterial disease evidenced by peripheral arterial revascularization procedure due to atherosclerotic disease
  • Peripheral arterial disease evidenced by amputation due to atherosclerotic disease

Documentation to bring

  • Completed, signed, and dated PA/DGA form (F-11049) Section V
  • Completed PA/RF
  • Supporting clinical information and copy of member's current medical records
  • Evidence that member has established cardiovascular disease (prior MI, prior stroke, or PAD documentation)
  • Member's current BMI documentation (≥ 27 kg/m²)
  • Member's current treatment plan including reduced-calorie diet and physical activity plan

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Initial renewal (up to 183 days): documentation that member continues to follow reduced-calorie diet and maintains physical activity; member must be on appropriate maintenance dose per Wegovy PI; member must be adherent with prescribed treatment regimen. Subsequent renewals (up to 365 days): same diet/activity documentation; appropriate maintenance dose; adherence required. No weight loss threshold specified for renewal.

Not covered when

  • Must be adherent with prescribed treatment regimen for renewal
  • Renewal requires member to be on appropriate maintenance dose per Wegovy prescribing information
  • Cannot be submitted via DAPO Center or STAT-PA system — portal, fax, or mail only

Policy note: ForwardHealth (Wisconsin Medicaid). This is a separate PA pathway from the general anti-obesity weight loss indication with different submission requirements (PA/DGA form Section V rather than the Anti-Obesity Drug Attachment F-00163). No weight loss threshold is required for renewal under this indication. Subsequent renewals approved for up to 365 days (vs. 183 days for initial/first renewal). The document does not specify that diabetes must be excluded — the indication is available to overweight/obese adults with established CVD regardless of diabetes status.

verified June 3, 2026 · source: Wisconsin Medicaid Medicaid prior authorization policy · View policy document (PDF)

Open on its own page →

Full requirements: Wegovy for Liver Disease (MASH) (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

MASH — Noncirrhotic MASH with moderate to advanced fibrosis

All of:

  • Wegovy prescribed consistent with FDA-approved labeling
  • Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis consistent with stages F2 to F3
  • Fibrosis confirmed by biopsy or noninvasive tests (FibroScan MRE + MRI-PDFF)
  • Member will use medication in conjunction with diet and exercise
  • Prescriber documents no significant alcohol consumption within the past year
  • Prescription written by a liver specialist physician (gastroenterologist or hepatologist)
  • Prescriber will monitor for elevations in liver tests and development of liver-related adverse reactions

Documentation to bring

  • Completed, signed, and dated PA/DGA form Section VI
  • Completed PA/RF
  • Supporting clinical information and copy of member's current medical records
  • Documentation of member's medical condition (noncirrhotic MASH with F2-F3 fibrosis)
  • Biopsy results or noninvasive test results (FibroScan MRE + MRI-PDFF) confirming F2-F3 fibrosis
  • Documentation of no significant alcohol consumption within the past year
  • Documentation of prescriber identity as liver specialist (gastroenterologist or hepatologist)
  • Details regarding previous medication use
  • Member's current treatment plan

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Initial renewal (up to 183 days): documentation that member is responding adequately to treatment as documented in laboratory tests; appropriate maintenance dose per Wegovy PI; adherence required. Subsequent renewals (up to 365 days): documentation of adequate treatment response via laboratory tests AND biopsy or noninvasive tests (FibroScan or MRE + MRI-PDFF) showing either resolution of steatohepatitis without worsening of fibrosis OR at least one stage improvement in fibrosis without worsening of steatohepatitis; appropriate maintenance dose; adherence required.

Not covered when

  • Cirrhotic MASH is excluded — only noncirrhotic MASH qualifies
  • Significant alcohol consumption within the past year is a disqualifier
  • Must be adherent with prescribed treatment regimen for renewal
  • Subsequent renewal requires documented histologic or imaging response
  • Cannot be submitted via DAPO Center or STAT-PA system — portal, fax, or mail only

Policy note: ForwardHealth (Wisconsin Medicaid). Separate PA pathway and submission form (PA/DGA Section VI) from general anti-obesity criteria. Requires prescription by a gastroenterologist or hepatologist. Noninvasive test confirmation described as 'FibroScan MRE (magnetic resonance enterography) + MRI-PDFF (proton density fat fraction)' — this appears to refer to FibroScan and/or MRE with MRI-PDFF. Subsequent renewals require objective evidence of treatment response (histologic or imaging). No BMI threshold is stated for the MASH indication specifically. Fibrosis staging F2-F3 (noncirrhotic).

verified June 3, 2026 · source: Wisconsin Medicaid Medicaid prior authorization policy · View policy document (PDF)

Open on its own page →

Questions people ask
Does Wisconsin Medicaid cover Wegovy?
Yes. Wisconsin Medicaid covers Wegovy for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with Wisconsin Medicaid?
Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Liver Disease (MASH) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does Wisconsin Medicaid require to renew Wegovy?
Weight Loss — Applies to Medicaid plans. Member must achieve at least 5% weight loss from baseline. Member must be taking an appropriate maintenance dose as outlined in Wegovy prescribing information. PA will not be renewed if BMI falls below 24. Maximum treatment period is 12 continuous months; after that, member must wait 6 months before requesting again. ForwardHealth allows only two lifetime weight loss attempts with Wegovy. Heart Disease Risk Reduction — Applies to Medicaid plans. Initial renewal (up to 183 days): documentation that member continues to follow reduced-calorie diet and maintains physical activity; member must be on appropriate maintenance dose per Wegovy PI; member must be adherent with prescribed treatment regimen. Subsequent renewals (up to 365 days): same diet/activity documentation; appropriate maintenance dose; adherence required. No weight loss threshold specified for renewal. Liver Disease (MASH) — Applies to Medicaid plans. Initial renewal (up to 183 days): documentation that member is responding adequately to treatment as documented in laboratory tests; appropriate maintenance dose per Wegovy PI; adherence required. Subsequent renewals (up to 365 days): documentation of adequate treatment response via laboratory tests AND biopsy or noninvasive tests (FibroScan or MRE + MRI-PDFF) showing either resolution of steatohepatitis without worsening of fibrosis OR at least one stage improvement in fibrosis without worsening of steatohepatitis; appropriate maintenance dose; adherence required.
How current is this information?
The oldest review date among the policies on this page is June 3, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Card and program names on file in Wisconsin

These names map to Wisconsin Medicaid, including older names and spelling variants. This is not a list of plans currently accepting members.

Also under Wisconsin Medicaid: Mounjaro, Ozempic, Zepbound

Wegovy under other plans: Elevance Health, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid, EmblemHealth

All insurance plans · All medications

Summary of Wisconsin Medicaid's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.