Medicaid
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (dyslipidemia, HTN, OSA, T2DM, and CVD)
- BMI at or above the 95th percentile for age and sex
- 6 months of a documented diet and exercise program
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
- To renew, the plan looks for at least 5% weight loss from the starting weight and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.
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: Pa policy