Wisconsin Medicaid coverage for Wegovy (Heart

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
Established cardiovascular disease (MI, stroke, and PAD)

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
To renew, the plan looks for 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: Pa policy

Wisconsin Medicaid coverage for Wegovy (Heart Disease Risk Reduction)