# Does DC Medicaid Cover Wegovy or Zepbound? Fee-for-Service and Both Plans Compared By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-07 Canonical page: https://glpwatchdog.org/research/dc-medicaid-glp1-coverage > The District's fee-for-service list excludes anti-obesity drugs, and AmeriHealth Caritas DC and MedStar Family Choice DC rule out weight loss too. How the two plans' heart, MASH and sleep apnea tests differ, what changed for Wellpoint members in August 2026, and how to appeal. ## Key points - The District's fee-for-service drug list, effective September 18, 2026, names anti-obesity drugs as an excluded class. - Wellpoint DC members moved to AmeriHealth Caritas DC on August 1, 2026, leaving two managed care plans. - AmeriHealth's Wegovy heart route starts at age 45 and turns away people with diabetes; MedStar's starts at 18 and needs a cardiologist. - For Zepbound, both plans set an apnea index floor of 15 and a BMI floor of 30; MedStar ends renewals once BMI falls under 30. - Plan appeals are due within 60 days of the notice, and a fair hearing within 90 to 120 days of the plan's decision. No. DC Medicaid does not pay for Wegovy, Zepbound or other GLP-1s prescribed for weight loss: the District’s fee-for-service drug list excludes anti-obesity drugs, and both managed care plans rule out weight loss as a covered use.[1][3][4] As of November 2026 the two plans, AmeriHealth Caritas DC and MedStar Family Choice DC, do cover Wegovy for heart-risk reduction or the liver disease MASH and Zepbound for sleep apnea with prior authorization, on tests that differ between them.[3][4] > **About this article.** This page reads the District’s Medicaid drug list, the Department of Health Care Finance’s notice on the 2026 plan change, and each managed care plan’s formulary and prior authorization criteria, as posted on November 7, 2026. DC Healthy Families is the managed care side of DC Medicaid. For the federal rule on weight-loss drugs, see [why Medicaid treats Ozempic and Wegovy differently](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy). ## Can DC Medicaid pay for a GLP-1 prescribed to lose weight? No, on any of the three rulebooks. The fee-for-service preferred drug list, effective September 18, 2026, names anti-obesity drugs among its excluded classes.[1] AmeriHealth Caritas DC’s policy is titled for non-weight-loss uses and lists a weight-loss diagnosis as an exclusion.[3] MedStar Family Choice DC says Zepbound cannot be approved for weight management and limits Wegovy to two other uses.[4] Under federal law, states and the District may leave weight-loss drugs out of Medicaid, so this is a local choice.[9] ## Which DC Medicaid rules apply to you? That depends on how you get your benefits. People in fee-for-service Medicaid follow the District’s drug list, run by Prime Therapeutics.[1] People in DC Healthy Families follow their plan’s formulary. Since August 1, 2026 there have been two plans: Wellpoint DC members were moved to AmeriHealth Caritas DC that day, and they can switch to MedStar Family Choice DC until January 31, 2027.[2] The District’s notice says benefits stay the same whichever plan you choose, but the drug criteria the two plans publish are not identical.[2][3][4] The fee-for-service list carries no Wegovy or Zepbound entry or criteria for heart disease or sleep apnea.[1] A fee-for-service member with one of those conditions should have the prescriber ask the pharmacy program directly how such a request is handled. ## How do the two DC Healthy Families plans compare? *Wegovy and Zepbound prior authorization in DC Healthy Families plans, criteria posted November 7, 2026* | Route | AmeriHealth Caritas DC (criteria updated April 1, 2026) | MedStar Family Choice DC (table effective October 1, 2026) | | --- | --- | --- | | Weight loss alone | Excluded | Not approvable | | Wegovy for heart risk | Age 45 or older; BMI ≥ 27; prior heart attack, stroke or symptomatic artery disease; on standard heart medicines; no type 1 or type 2 diabetes; A1c 6.5% or lower | Age 18 or older; BMI ≥ 27 measured in the past 90 days; prior heart attack, stroke or symptomatic artery disease; a cardiologist prescribes or consults | | Wegovy for MASH | Fibrosis F2 to F3 by biopsy or a noninvasive test; liver, digestive or hormone specialist involved; lifestyle counseling; limited alcohol | Fibrosis F2 or F3 by biopsy or a noninvasive test within 180 days; gastroenterologist or hepatologist; no other liver disease or cirrhosis | | Zepbound for sleep apnea | BMI ≥ 30; AHI ≥ 15 while on PAP, or after PAP failed or cannot be used; failed lifestyle changes; sleep specialist involved | Age 18 or older; no type 1 or type 2 diabetes; AHI ≥ 15 on a sleep study within 6 months; BMI ≥ 30 | | Approval length | 6 months, then 12-month renewals | 6 months, with 6-month renewals | Three differences matter most. AmeriHealth’s heart route starts at age 45 and turns away anyone with diabetes, while MedStar’s starts at 18 but needs a cardiologist.[3][4] Zepbound’s label covers moderate to severe sleep apnea in adults with obesity.[11] AmeriHealth accepts a sleep apnea request from someone who could not use PAP, while MedStar does not mention PAP but excludes people with diabetes.[3][4] And at renewal, AmeriHealth asks sleep apnea patients to show a 5% weight loss, while MedStar requires a repeat sleep study once treatment passes 12 months and refuses renewal if BMI has fallen below 30.[3][4] Those last two rules can collide with success: a person who loses enough weight on Zepbound to drop under a BMI of 30 loses MedStar coverage at renewal.[4] For Wegovy, MedStar refuses renewal at a BMI of 24 or below.[4] Our guides to [Zepbound for sleep apnea](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) and [GLP-1s and MASH](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) cover what the trials behind these uses showed. Both plans list a fallback when criteria are not met. AmeriHealth sends such requests to a medical director or clinical reviewer for medical necessity review, and MedStar runs a medical exception process by phone at 855-798-4244.[3][5] MedStar’s formulary lists Wegovy and Zepbound for ages 18 and up, with the lower titration strengths limited to four pens a year.[5] ## Does DC Medicaid cover Ozempic and Mounjaro for diabetes? Yes. On the fee-for-service list, generic liraglutide, the Ozempic injection and Trulicity are preferred, while Mounjaro, Ozempic tablets, Rybelsus and Victoza are non-preferred and need prior authorization.[1] MedStar’s diabetes form is stricter. It asks for type 2 diabetes with an A1c of at least 7.5%, or heart disease plus a BMI of 27 or more and an A1c of 6.5% or more, plus three-month trials of two other diabetes drugs and of liraglutide before Mounjaro, Ozempic or Trulicity.[6] None of these is covered for weight loss. ## What about children and teens? Wegovy’s label includes obesity treatment from age 12, but neither plan covers weight loss, and MedStar lists both drugs for adults only.[10][5] Federal law requires Medicaid to provide necessary treatment found through child health screening for people under 21, even when the plan of benefits leaves it out.[12] We found no DC document that applies that rule to GLP-1s. A family can ask in writing for a medical necessity review under EPSDT, the federal child-health benefit, by name. ## How do you appeal a denial in DC? - **Requests.** MedStar takes GLP-1 requests by fax at 202-243-6258 and must decide within 24 hours, so send complete records the first time.[6][5] - **Plan appeal.** Managed care members have 60 calendar days from the date on the denial notice to appeal to the plan.[7] - **Fair hearing.** If the plan upholds the denial, federal rules give at least 90 and at most 120 days from the plan’s decision notice to request a fair hearing. The notice states the exact window.[8] An appeal has the most to work with when the dispute is over a covered use, such as whether a stent counts as established heart disease or whether a sleep study is recent enough. Our walkthrough of [prior authorization and appeals](https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals) covers what to send, and the [state Medicaid GLP-1 checker](https://glpwatchdog.org/tools/state-medicaid-glp1-checker) compares other states. ## What are the options without coverage? Paying cash is the main one. Lilly’s savings card for insured patients excludes Medicaid enrollees.[13] Self-pay prices in the figures we track are $349 a month for most Wegovy pen doses from Novo Nordisk, and from $299 at the starting dose, $399 at 5 mg and $449 at higher doses refilled on time for Lilly’s self-pay Zepbound.[13][14] Read each offer’s terms on government-program enrollment first. Our list of the [cheapest GLP-1 routes without insurance](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them. ## Frequently asked questions ### Does DC Medicaid cover Wegovy for weight loss? No. As of November 2026, the fee-for-service drug list excludes anti-obesity drugs and both DC Healthy Families plans rule out weight loss. Wegovy can be approved with prior authorization for heart-risk reduction after a heart attack, stroke or artery disease, or for MASH with stage F2 or F3 fibrosis. ### Does DC Medicaid cover Zepbound for sleep apnea? Yes, through both managed care plans, with prior authorization. Each asks for an apnea-hypopnea index of at least 15 and a BMI of at least 30. MedStar Family Choice DC also excludes people with diabetes, and AmeriHealth Caritas DC accepts people who could not use PAP therapy. ### Does AmeriHealth Caritas DC cover Wegovy? Only for non-weight-loss uses. For heart-risk reduction the member must be at least 45, have a BMI of 27 or more, have had a heart attack, stroke or symptomatic artery disease, take standard heart medicines and not have diabetes. Wegovy is also covered for MASH with F2 to F3 fibrosis. ### What happened to Wellpoint DC Medicaid members? On August 1, 2026, Wellpoint DC members were moved to AmeriHealth Caritas DC. They can ask to switch to MedStar Family Choice DC until January 31, 2027. A new GLP-1 prescription after the move goes through AmeriHealth's criteria. ### Does DC Medicaid cover Ozempic? Yes, for type 2 diabetes. The Ozempic injection is preferred on the fee-for-service list. MedStar Family Choice DC requires an A1c of at least 7.5%, or heart disease with a BMI of at least 27, plus trials of other diabetes drugs first. ## References 1. District of Columbia Department of Health Care Finance; Prime Therapeutics State Government Solutions Pharmacy Preferred Drug List (PDL), effective September 18, 2026. dc.fhsc.com. 2026. https://dc.fhsc.com/downloads/providers/DCRx_PDL_listing.pdf 2. District of Columbia Department of Health Care Finance Letter to DC Medicaid managed care enrollees on the Wellpoint DC transition to AmeriHealth Caritas DC, effective August 1, 2026. dhcf.dc.gov. 2026. https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/070126%20WP%20EnrolleeLtr%20Website%20With%20Logos.pdf 3. AmeriHealth Caritas District of Columbia Pharmacy prior authorization criteria (updated April 1, 2026): GLP-1 Receptor Agonists (Wegovy/Zepbound) for Non-Weight Loss Indications. amerihealthcaritasdc.com. 2026. https://www.amerihealthcaritasdc.com/content/dam/amerihealth-caritas/acdc/pdf/provider/pharmacy-prior-authorization-criteria.pdf.coredownload.inline.pdf 4. MedStar Family Choice District of Columbia Prior Authorization and Step Therapy Table, effective October 1, 2026. medstarfamilychoicedc.com. 2026. https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/pharmacy-materials/dc-pa-and-st-table---effective-10-1-2026.pdf 5. MedStar Family Choice District of Columbia DC Healthy Families Formulary, effective October 1, 2026. medstarfamilychoicedc.com. 2026. https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/pharmacy-materials/medstar-family-choice-of-dc-formulary-effective-100126.pdf 6. MedStar Family Choice District of Columbia GLP-1 Prior Authorization Form (Mounjaro, Ozempic, Trulicity). medstarfamilychoicedc.com. 2026. https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/pharmacy-materials/glp_pa_form-update-11-26.pdf 7. Code of Federal Regulations 42 CFR §438.402: Grievance and appeal system, general requirements. eCFR. 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.402 8. Code of Federal Regulations 42 CFR §438.408: Resolution and notification of grievances and appeals. eCFR. 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408 9. United States Code 42 U.S.C. §1396r-8: Payment for covered outpatient drugs (Social Security Act §1927). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396r-8 10. Novo Nordisk WEGOVY (semaglutide) injection and tablets: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b 11. Eli Lilly and Company ZEPBOUND (tirzepatide) injection: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b 12. United States Code 42 U.S.C. §1396d: Definitions, including early and periodic screening, diagnostic, and treatment services (subsection r). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396d 13. Eli Lilly and Company Zepbound savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings 14. Novo Nordisk Wegovy savings offer. novocare.com. 2026. https://www.novocare.com/obesity/products/wegovy/savings-offer.html --- Cite as: GLP Watchdog, Nora Bissett, "Does DC Medicaid Cover Wegovy or Zepbound? Fee-for-Service and Both Plans Compared", published 2026-11-07. https://glpwatchdog.org/research/dc-medicaid-glp1-coverage Canonical HTML page: https://glpwatchdog.org/research/dc-medicaid-glp1-coverage Medical disclaimer: Nothing here is medical advice. We report on this subject; we do not treat anyone. Whether to begin a medication, supplement, or treatment, whether to adjust it, and whether to stop are questions for a clinician licensed to answer them, who knows your history.