# West Virginia Medicaid and Wegovy or Zepbound: The Heart, Liver and Sleep Apnea Routes By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-07 Canonical page: https://glpwatchdog.org/research/west-virginia-medicaid-glp1-coverage > West Virginia Medicaid will not pay for Wegovy or Zepbound to lose weight. Its own criteria cover Wegovy after a heart attack, stroke or artery disease (no diabetes allowed) or for MASH, and Zepbound for sleep apnea, the same for every health plan. ## Key points - Weight loss alone gets no coverage: both state criteria call weight-loss drugs a benefit exclusion. - Wegovy for heart prevention needs a past heart attack, stroke or artery disease, BMI 27 or higher, and no diabetes. - Wegovy for MASH needs a biopsy or a liver stiffness scan and a liver or digestive specialist. - Zepbound for sleep apnea needs an AHI of at least 15 and a BMI from 30 up; CPAP only has to be prescribed or discussed. - Pharmacy is run by the state, not the four health plans, and a hearing request is due within 90 days. No. As of November 2026, West Virginia Medicaid treats drugs used for weight loss as a benefit exclusion, so it will not pay for Wegovy or Zepbound to lose weight.[1][2] It does cover three narrower uses with prior authorization: Wegovy after a heart attack, stroke or symptomatic artery disease, Wegovy for the liver disease MASH, and Zepbound for moderate to severe sleep apnea in adults with obesity.[1][2][3] > **About this article.** This page reads the West Virginia Bureau for Medical Services’ Wegovy criteria (effective January 1, 2026), its Zepbound criteria (effective July 1, 2025) and its preferred drug list effective October 1, 2026, as they stood on November 7, 2026. The state revises the drug list each quarter, so check the current file before filing. To compare states, use the [state Medicaid GLP-1 checker](https://glpwatchdog.org/tools/state-medicaid-glp1-checker). ## Will West Virginia Medicaid pay for Wegovy or Zepbound to lose weight? It does not. Both criteria documents open the same way, stating that the program normally excludes drugs taken to lose weight and will consider each drug only for the uses the document names.[1][2] Federal Medicaid law gives states that option, listing weight-loss drugs among the few classes a program may leave out.[8] Our explainer on [why Medicaid pays for Ozempic but often not Wegovy](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy) covers the federal side. One structural point helps West Virginians. About 87% of members are in one of four Mountain Health Trust managed care plans, but point-of-sale pharmacy is carved out of managed care.[5] The state runs the drug benefit itself, so the criteria below apply the same way whether a member is with Aetna Better Health, The Health Plan, Highmark Health Options or Wellpoint. Our guide to [how managed care plans set GLP-1 rules](https://glpwatchdog.org/research/medicaid-managed-care-and-glp1s) explains why that differs from state to state. ## Which GLP-1 uses does West Virginia Medicaid cover? Four, counting diabetes. The October 2026 drug list files Wegovy in its own classes for heart-event reduction and for MASH, puts Zepbound in a sleep apnea class, and keeps the diabetes drugs in a separate class.[3] *West Virginia Medicaid GLP-1 rules by use, from the BMS criteria and the preferred drug list effective October 1, 2026* | Use | Drug | Drug list status | Main requirements | | --- | --- | --- | --- | | Weight loss alone | Wegovy, Zepbound | Benefit exclusion | No route | | Type 2 diabetes | Ozempic injection, Trulicity, Victoza | Preferred, with PA | Type 2 diabetes diagnosis | | Type 2 diabetes, other brands | Mounjaro, Rybelsus, Ozempic tablets, Byetta, liraglutide | Non-preferred | A1C of 7% or more; 90-day trials of every preferred agent | | Heart attack, stroke or artery disease | Wegovy injection or tablets | Preferred, with PA | BMI of 27 or more; no diabetes; A1C of 6.5% or less; heart, vascular or neurology prescriber | | MASH with F2 to F3 fibrosis | Wegovy | Preferred, with PA | Biopsy or elastography; gastroenterology or hepatology prescriber | | Moderate to severe sleep apnea | Zepbound | Listed, with PA | AHI of 15 or more; BMI of 30 or more; CPAP prescribed or discussed | ## What does West Virginia require for Wegovy after a heart attack or stroke? The heart route is the strictest of the three. The patient needs a BMI of 27 or more, with the date and value of the last reading on the request, and at least one qualifying event: a prior heart attack, a prior stroke, or symptomatic peripheral artery disease shown by an ankle-brachial index of 0.85 or lower, a revascularization or an amputation from atherosclerosis.[1] The prescriber must be, or consult, a doctor or specialty-trained clinician in cardiology, vascular surgery or neurology.[1] The diabetes line is the one that catches people. The request must include an A1C from the past six months, and the patient must have no diabetes of either type and no A1C above 6.5%.[1] That is narrower than the Wegovy label, whose heart indication reaches adults with overweight as well as obesity and says nothing to exclude diabetes.[10] A person with diabetes and heart disease is sent to the diabetes class instead, where Ozempic, the same medicine as Wegovy at lower doses, is a preferred drug.[3] The first approval lasts 90 days, and later approvals run six months. A renewal must show the patient is on a maintenance dose such as 1.7 mg or 2.4 mg a week; the criteria say treatment should stop if 1.7 mg cannot be tolerated.[1] ## Will West Virginia Medicaid cover Wegovy for fatty liver disease (MASH)? Yes, for noncirrhotic MASH with stage 2 or stage 3 fibrosis, the same range as the label, which the FDA approved on an accelerated basis.[1][10] West Virginia asks for proof that most states leave open: either a liver biopsy from the past year with an activity score of 4 or more, or a liver stiffness test by transient elastography such as FibroScan or by MR elastography.[1] A gastroenterology or hepatology prescriber must write or consult on the request, and the file needs a record of diet, exercise and weight counseling from the past 12 months.[1] Patients with both diabetes and MASH are told to have their diabetes treated with a GLP-1 approved for diabetes, which in practice points to the preferred diabetes list.[1] The first MASH approval lasts 90 days and later ones up to a year; a renewal needs a documented response and no progression to cirrhosis.[1] Wegovy is the preferred MASH drug on the October list, with Rezdiffra non-preferred.[3] Our page on [semaglutide for MASH](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) covers the trial behind the approval. ## Does West Virginia Medicaid cover Zepbound for sleep apnea? Yes, within the label’s adult obesity limits.[2][9] The request needs a sleep study from the past 12 months showing an AHI (apnea-hypopnea index) of 15 or more events an hour, and a BMI of 30 or more recorded in the past three months.[2] On CPAP, the wording is soft: the patient must have been prescribed CPAP or counseled on it as a possible therapy, so a failed CPAP trial is not required.[2] The patient must also receive ongoing diet and activity counseling and must not use Zepbound with another tirzepatide product.[2] Unlike some states, West Virginia does not shut out people with diabetes here. A patient with type 2 diabetes must first have taken a preferred diabetes GLP-1 for three months without success.[2] The first approval lasts 150 days, fills are limited to 30 days, and renewals run six months. To renew, the patient must tolerate at least the 10 mg dose, show better sleep apnea symptoms or AHI, and have lost more than 5% of body weight or kept off an earlier 5% loss.[2] Our guide to [Zepbound for sleep apnea](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) explains the trials behind the indication. ## How does a prescriber file the request? Each criteria document has its own prior authorization request form attached.[1][2] The state hands pharmacy reviews to the Rational Drug Therapy Program at WVU’s pharmacy school; forms go by fax to (800) 531-7787, and the program’s pharmacists answer questions at (800) 847-3859.[4] Because every injectable drug on West Virginia Medicaid needs prior authorization, the diabetes GLP-1s need one too, though the preferred ones only require the diagnosis.[3][4] ## How do you appeal a West Virginia Medicaid denial? Read the reason first. A missing A1C, an old sleep study or a BMI reading older than three months can often be fixed with a new request carrying the record.[1][2] A denial for weight loss alone has little to argue, because no route exists for it.[1] For a fair hearing, the state’s hearing manual allows 90 days from the effective date of the action, and it lists denial of Medicaid coverage for a service among the decisions that can be heard.[6] The Board of Review in the Office of Inspector General takes requests in writing or by phone, at OIGBOR@wv.gov or 304-352-0805, and has an online form.[7] Our walkthrough of [GLP-1 prior authorization and appeals](https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals) covers what to put in the file, and the [West Virginia state page](https://glpwatchdog.org/states/west-virginia) gathers the state’s facts in brief. ## What are the options if West Virginia Medicaid will not pay? Manufacturer copay cards are off the table: Lilly’s savings card terms rule out people on Medicaid and other public coverage.[11] Cash prices in the figures we track are $349 a month for most Wegovy pen doses through Novo Nordisk, and $299 at the starting dose, $399 at 5 mg and $449 at higher doses refilled on time for Lilly’s self-pay Zepbound.[11][12] Check each program’s terms on government coverage before you enroll. Our list of the [lowest-cost GLP-1 routes without insurance](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them. ## Frequently asked questions ### Does West Virginia Medicaid cover Wegovy for weight loss? No. West Virginia Medicaid treats weight-loss drugs as a benefit exclusion. As of November 2026 it considers Wegovy only to prevent another heart event in adults with a prior heart attack, stroke or symptomatic artery disease, or to treat MASH with stage 2 or 3 liver fibrosis, each with prior authorization. ### Does West Virginia Medicaid cover Zepbound? Only for sleep apnea. Zepbound needs a sleep study from the past year with an AHI of 15 or more, a BMI of 30 or more from the past three months, and a record that CPAP was prescribed or discussed. It is not covered for weight loss alone. ### Can I get Wegovy for heart disease on West Virginia Medicaid if I have diabetes? Not through the Wegovy heart route. The January 2026 criteria exclude anyone with type 1 or type 2 diabetes or an A1C above 6.5%. People with diabetes use the diabetes drug class instead, where Ozempic, Trulicity and Victoza are preferred. ### Does my Medicaid health plan in West Virginia have its own GLP-1 rules? No. Pharmacy is carved out of West Virginia's managed care program, so the state's own drug list and criteria apply whether you are with Aetna Better Health, The Health Plan, Highmark Health Options or Wellpoint. ### What is the deadline to appeal a West Virginia Medicaid denial? The state's hearing manual allows 90 days from the effective date of the action. You can ask the Board of Review for a fair hearing in writing, by email or by phone, and the notice you received should name the date the clock starts. ## References 1. West Virginia Bureau for Medical Services, Office of Pharmacy Services Prior Authorization Criteria: Wegovy (semaglutide), effective January 1, 2026. bms.wv.gov. 2026. https://bms.wv.gov/media/40897/download 2. West Virginia Bureau for Medical Services, Office of Pharmacy Services Prior Authorization Criteria: Zepbound (tirzepatide), effective July 1, 2025. bms.wv.gov. 2025. https://bms.wv.gov/media/40699/download 3. West Virginia Bureau for Medical Services Preferred Drug List and Prior Authorization Criteria, effective October 1, 2026. bms.wv.gov. 2026. https://bms.wv.gov/media/41460/download?inline 4. West Virginia Bureau for Medical Services Prior Authorization Criteria (pharmacy program page). bms.wv.gov. 2026. https://bms.wv.gov/page/prior-authorization-criteria 5. West Virginia Bureau for Medical Services Mountain Health Trust (managed care). bms.wv.gov. 2026. https://bms.wv.gov/members/mountain-health-trust-managed-care 6. West Virginia Office of Inspector General Common Chapters Manual, Chapter 700: Hearings Held by Board of Review (revised August 22, 2024). oig.wv.gov. 2024. https://oig.wv.gov/media/1696/download?inline 7. West Virginia Office of Inspector General Board of Review: requesting a fair hearing. oig.wv.gov. 2026. https://oig.wv.gov/BOR 8. 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 9. 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 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 savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings 12. Novo Nordisk Wegovy savings offer. novocare.com. 2026. https://www.novocare.com/obesity/products/wegovy/savings-offer.html --- Cite as: GLP Watchdog, Nora Bissett, "West Virginia Medicaid and Wegovy or Zepbound: The Heart, Liver and Sleep Apnea Routes", published 2026-11-07. https://glpwatchdog.org/research/west-virginia-medicaid-glp1-coverage Canonical HTML page: https://glpwatchdog.org/research/west-virginia-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.