HealthRX.com · Printable coverage checklist
State Medicaid Wegovy request and hearing worksheet
Find your state's own Wegovy document before anything else, record which indication the request is for, gather the records state criteria usually ask for, and log each decision. The federal deadline for appealing to a managed-care plan is printed so a denial does not run out the clock.
Your state program
State and Medicaid program name
Fee-for-service or managed-care plan (name)
Title and date of the state's Wegovy criteria or preferred drug list
Indication on the requestweight management, cardiovascular risk reduction or MASH
Records state criteria commonly ask for
- Height, weight and BMI with the date measured
- Diagnosis codes for each condition the request relies on
- Records of a diet, activity or behavioral program and how long it ran
- Earlier weight-loss medicines with dates, doses and outcomes
- For cardiovascular risk reduction: records of the heart attack, stroke or arterial disease
- For MASH: the fibrosis test result and its date
- Prescriber statement on thyroid cancer and MEN 2 history
What four state documents and CMS say
- California's Medi-Cal Rx stopped covering Wegovy for weight loss on January 1, 2026, apart from medical-necessity review for members under 21.[1]
- West Virginia considers Wegovy only for secondary cardiovascular prevention or MASH.[2]
- Missouri covers Wegovy for two diagnoses, not for weight reduction.[3]
- Kentucky approves Wegovy for 6 months at a time.[4]
- State Medicaid agencies can join CMS's BALANCE model from May 2026 through January 1, 2027.[5]
Appeal deadline in managed care
- Federal rules give a managed-care member 60 calendar days from the date on the denial notice to ask the plan for an appeal, by phone or in writing. Fee-for-service members follow the state's fair hearing rules in the notice.[6]
Decisions and deadlines
| Date | Request, denial or appeal | Reason given | Deadline | Next step |
|---|---|---|---|---|
Ask the state program or plan
- Is Wegovy covered for the indication on my prescription, and under which criteria document?
- Does my managed-care plan follow the state's preferred drug list for this drug?
- How long does an approval last, and what is needed to renew it?
- Has the state applied to join the BALANCE model, and would that change weight-loss coverage?
- Where do I send an appeal, and when does my fair hearing deadline run out?
Sources for the facts on this sheet
- California Department of Health Care Services, Medi-Cal Rx. GLP-1 Coverage Considerations (December 12, 2025; last updated April 6, 2026). Accessed 2026-10-18. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2025/12_A_GLP-1_Coverage_Considerations.pdf
- West Virginia Department of Human Services, Bureau for Medical Services. Office of Pharmacy Services Prior Authorization Criteria: Wegovy (semaglutide), effective 1/01/2026. Accessed 2026-10-18. https://bms.wv.gov/media/40897/download
- Missouri Department of Social Services, MO HealthNet Division. GLP-1 Receptor Agonists for All Indications: Prior Authorization (form 2575-053, April 2026). Accessed 2026-10-18. https://dss.mo.gov/sites/mydss/files/media/pdf/2026/07/2575-053-GLP-1-Receptor-Agonists-PA-Form-Tahoma.pdf
- Kentucky Medicaid pharmacy program (MedImpact). Prior Authorization Criteria, Kentucky Medicaid: Wegovy (semaglutide). Accessed 2026-10-18. https://kyportal.medimpact.com/sites/default/files/2026-01/wegovy_pa_criteria_1.3.2026.pdf
- Centers for Medicare & Medicaid Services. BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model | CMS. Accessed 2026-10-18. https://www.cms.gov/priorities/innovation/innovation-models/balance
- Electronic Code of Federal Regulations (eCFR). 42 CFR 438.402 -- General requirements (grievance and appeal system). Accessed 2026-10-18. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.402
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.