New York Medicaid does not cover Wegovy when it’s prescribed for weight loss. The state’s pharmacy program, NYRx, has never covered any drug for that purpose. There is one narrow path to coverage: Wegovy’s separate FDA-approved use for reducing cardiovascular risk in certain patients with established heart disease and severe obesity. That pathway comes with strict clinical criteria and prior authorization.
Why Weight Loss Is Excluded
Two laws stack on top of each other here. Federal law, in Section 1927(d)(2) of the Social Security Act, lets state Medicaid programs refuse to cover drugs used for “anorexia, weight loss, or weight gain.”1KFF. Medicaid Coverage of and Spending on GLP-1s New York took that option. State regulation 18 NYCRR § 505.3(g)(3) says “no payment will be made for any drug which has weight reduction as its sole clinical use.”2Cornell Law Institute. 18 NYCRR § 505.3
NYRx names Wegovy directly. Its pharmacy benefits page lists Wegovy, Ozempic, Qsymia, and Mounjaro as drugs that are “not covered by NYRx when prescribed for weight loss,” and states that “weight loss has never been a Medicaid-approved reason for covering a drug.”3NYRx. Pharmacy Benefits The January 2025 Medicaid Update from the New York State Department of Health repeated the same exclusion.4New York State Department of Health. Medicaid Update January 2025
The Cardiovascular Coverage Path
In March 2024, the FDA approved Wegovy for a second use: reducing the risk of cardiovascular death, heart attack, and stroke in adults who have established cardiovascular disease and are either obese or overweight.5U.S. Food and Drug Administration. FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults With Obesity or Overweight That indication isn’t weight loss, and federal law doesn’t permit states to exclude it.1KFF. Medicaid Coverage of and Spending on GLP-1s
New York’s Drug Utilization Review Board approved prior authorization criteria for this use at its February 27, 2025 meeting.6New York State Department of Health. DUR Board Meeting Summary, February 2025 To qualify for an initial authorization, a patient must meet all of the following:
- Documented cardiovascular disease: a prior heart attack, stroke, or peripheral arterial disease.
- A BMI of 40 or higher.
- No type 1 or type 2 diabetes. Patients with diabetes are expected to use other covered GLP-1 drugs.
- At least six months on prescribed cardiovascular medications, such as blood pressure, cholesterol, or anti-clotting drugs.
- At least six months of comprehensive lifestyle changes before starting Wegovy, including a reduced-calorie diet, increased physical activity, and behavioral modifications.
Initial authorization lasts up to six months. Renewals can extend up to 12 months. The program limits patients to two treatment attempts per lifetime. The Department of Health has said it intends to use these criteria as a template for other GLP-1 drugs prescribed outside of diabetes treatment.6New York State Department of Health. DUR Board Meeting Summary, February 2025
Can a Managed Care Plan Cover It Instead?
No. Before April 2023, individual Medicaid managed care organizations in New York ran their own pharmacy benefits, which left some room for plan-level formulary differences. The state then moved all mainstream Medicaid managed care enrollees onto NYRx, which pays pharmacies directly using a single statewide drug list.7New York State Department of Health. Pharmacy Transition Managed care plans no longer deliver the pharmacy benefit for these members and cannot add weight loss drugs to coverage on their own.8New York State Department of Health. Pharmacy Transition FAQ The transition does not apply to Managed Long Term Care plans, the Essential Plan, or Child Health Plus.
What Related Treatments Medicaid Will Cover
If you have type 2 diabetes, NYRx covers several GLP-1 receptor agonists, subject to clinical criteria. The preferred drug list includes Ozempic, Trulicity, Victoza, and exenatide.9NYRx. Preferred Drug Quick List Mounjaro is also covered for diabetes.3NYRx. Pharmacy Benefits Only one GLP-1 can be used at a time. Non-preferred GLP-1s require prior authorization, and switching drugs or doses while more than 25% of a current fill remains also triggers a prior authorization request.10NYRx. NYRx Exclusion/Override Notification
For obesity itself, Medicaid covers bariatric surgery with prior authorization, including gastric bypass, sleeve gastrectomy, and adjustable gastric banding.11George Washington University. Medicaid Obesity Coverage – New York Hospital-based weight management programs, such as the one at NYC Health + Hospitals/Bellevue, are generally covered subject to medical necessity, and typically combine medical weight management, intensive nutritional treatment, and behavioral counseling.12NYC Health + Hospitals. Bariatric Surgery and Weight Management Stand-alone adult obesity behavioral counseling is not explicitly defined in state policy; providers are expected to address nutrition and physical fitness during regular office visits.
Paying Out of Pocket
Discount options are limited for Medicaid enrollees. Novo Nordisk’s Wegovy savings card excludes anyone receiving benefits from a government-funded health program, including Medicaid.13NovoCare. Wegovy Savings Offer The company’s Patient Assistance Program requires applicants to certify they are not enrolled in or eligible for Medicaid, and its 2025 application does not list Wegovy among eligible medications.14NovoCare. Patient Assistance Program Application
The list price for injectable Wegovy is $1,349 per month.15Medical News Today. Wegovy Cost An oral version, approved by the FDA in December 2025 and launched in January 2026, has a starting-dose price of $149 per month for self-pay patients.16CNN. Wegovy Pill FDA Approval The federal TrumpRx site lists the Wegovy pill at $149 per month and the pen at $199 per month, though whether an individual Medicaid enrollee paying cash can access those prices is not clear from the available information.17TrumpRx. TrumpRx
What Could Change
Two bills in New York’s 2025-2026 session would require Medicaid to cover anti-obesity medications. Senate Bill S5798, sponsored by Senator Luis R. Sepúlveda, would require coverage of FDA-approved prescription drugs for chronic weight management in adults with obesity who have at least one weight-related condition.18New York State Senate. Senate Bill S579819New York State Senate. Assembly Bill A271520New York State Assembly. Bill S05798 Actions21LegiScan. NY Assembly Bill A02715 A predecessor bill in the prior session also failed to advance.
At the federal level, CMS launched the voluntary BALANCE model in December 2025, a five-year initiative in which CMS negotiates GLP-1 pricing and coverage terms on behalf of participating state Medicaid programs and Medicare Part D plans. The Medicaid component launched in May 2026, with a state application deadline of July 31, 2026.22Centers for Medicare and Medicaid Services. BALANCE Model Whether New York plans to participate has not been publicly confirmed.