Does Medicaid cover Wegovy?

Wegovy is the first weight loss drug approved by the Food and Drug Administration (FDA) since 2014. This weekly injection is one of the new weight loss drugs that contains semaglutide, part of a class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists. These medications mirror the GLP-1 hormone that is released in the gastrointestinal tract in response to eating. They not only stimulate the production of insulin to reduce blood sugar but also decrease appetite and slow the emptying of the stomach. 

The FDA approved Wegovy for weight loss for adults with a body max index (BMI) of 30 or higher and for adults with a BMI of 27 or higher with at least one weight-related health condition, such as heart disease). It is also approved for weight loss in children ages 12 and older whose weight is above the 95 percentile for their age and gender. Many insurance plans cover Wegovy for weight loss for patients who meet the criteria, but coverage may vary within each insurance plan, so it is important to check with your provider. Furthermore, Medicaid coverage for Wegovy depends upon where you live since every state decides what prescription drugs to cover through Medicaid.

Does Medicaid cover Wegovy 

In 1990, the Federal Medicaid Drug Rebate Program (MDRP) allowed the exclusion of certain classes of medication, including weight-loss drugs, from Medicaid coverage. As of July 2023, nine states—California, Connecticut, Delaware, Michigan, Minnesota, Pennsylvania, Rhode Island, Virginia, and Wisconsin—have added Wegovy to Medicaid preferred drug lists that allow patients to receive coverage without undergoing “step therapy,” where they are required to try less expensive drugs first. Other states may offer limited coverage, requiring beneficiaries to pay out of pocket for a portion of the cost. Within Medicaid in most states, beneficiaries may have to choose a managed care plan—each with a different formulary. So even if Medicaid covers Wegovy in a certain state for weight loss, you’ll have to ensure your plan covers it, too. 

The increasing number of states offering Medicaid coverage for weight loss drugs reflects the growing opinion among lawmakers that obesity is a disease requiring medical treatment. Because the prevalence of obesity among Medicaid beneficiaries is about 44%, more states may follow as they look for ways to reduce the cost of caring for patients with obesity-related comorbidities. Most states that include Wegovy on the preferred drug list require prior authorization and qualified patients who meet the FDA criteria for BMI. But each state has its own rules. For example, Virginia prohibits access to Wegovy for people under 18. 

To find out if your state’s Medicaid covers Wegovy or other medicines for obesity and weight loss management, visit the Wegovy website or contact your state’s Medicaid office.

How much does Wegovy cost?

The cost of Wegovy depends on many factors. For those on Medicaid, coverage, and cost will depend upon the state in which they live and the Medicaid plan in which they are enrolled. For those with insurance, the cost will be determined by the specifics of each plan, each person’s deductible, copay, and any limits on coverage. The typical cash price for Wegovy for people who are not insured is $1,811.35 for four weekly injections.

There are a few ways to save on Wegovy if your insurance does not cover the medication. One is to use your SingleCare Prescription Discount Card to pay $1,234 for a month’s supply of Wegovy. If insurance does not cover Wegovy, or if you pay cash for your prescriptions, Novo Care also offers a manufacturer’s coupon for up to $500 in savings for a 28-day supply.

How to check whether your Medicaid plan covers Wegovy

Medicaid coverage of Wegovy, which is currently approved solely for weight loss, is limited and depends on where you live. Every state decides what prescription drugs to cover through Medicaid. As of July 2023, California, Connecticut, Delaware, Michigan, Minnesota, Pennsylvania, Rhode Island, Virginia, and Wisconsin are the only states that cover Wegovy without requiring Medicaid beneficiaries to try less expensive drugs first. An additional six states offer limited coverage. The best way to find out if Wegovy is covered by your state, or whether you’ll have to pay a copay is to contact your state’s Medicaid agency.