Virginia Medicaid does cover Ozempic, but only when it is prescribed for type 2 diabetes and only after the prescriber gets prior approval. For weight loss, Virginia Medicaid will not cover Ozempic at all. If you need a semaglutide medication for obesity, the drug your plan may cover is Wegovy, and only if you meet a specific set of medical criteria.
Ozempic for Type 2 Diabetes
Ozempic is FDA-approved to treat type 2 diabetes, and federal law requires state Medicaid programs to cover FDA-approved drugs for their approved uses. Virginia follows that rule, with a catch: under the 2023 Virginia Appropriations Act, the Department of Medical Assistance Services (DMAS) requires service authorization for “newer diabetic drugs,” a category that includes GLP-1 receptor agonists like Ozempic. To get approval, your prescriber has to document your diabetes diagnosis and show that traditional diabetes drugs have not worked for you.1Virginia Legislative Information System. DMAS Report on Newer Diabetic Drugs
Nearly every Virginia Medicaid member is enrolled in a managed care organization rather than fee-for-service, so the exact rules depend on your plan. Virginia contracts with several MCOs, including Anthem HealthKeepers Plus, UnitedHealthcare Community Plan, Aetna, Molina, and Sentara, and each maintains its own formulary and prior authorization requirements.2Virginia DMAS. Prescription Drug Formularies Check your plan’s formulary or call its pharmacy line to confirm what your prescriber needs to submit.
Ozempic Is Not Covered for Weight Loss
If you want Ozempic to lose weight, Virginia Medicaid will not pay for it. The DMAS service authorization form for anti-obesity drugs leaves Ozempic off the approved list and requires patients seeking a covered weight-loss drug to confirm they are “not concurrently on Victoza or Ozempic or other GLP-1 inhibitors.”3Virginia Medicaid Pharmacy Services. Service Authorization Form for Anti-Obesity Drugs That has a practical consequence: if you already take Ozempic for diabetes, you cannot also get a covered weight-loss drug like Wegovy on top of it. To treat obesity with semaglutide through Virginia Medicaid, your provider has to prescribe Wegovy instead of Ozempic.
Wegovy Coverage and What You Need to Qualify
Virginia is one of roughly 13 states whose Medicaid programs still cover GLP-1 drugs for obesity, a category that is optional under federal law.4KFF. Medicaid Coverage of and Spending on GLP-1s The criteria are strict.
Under fee-for-service, DMAS requires all of the following for Wegovy:3Virginia Medicaid Pharmacy Services. Service Authorization Form for Anti-Obesity Drugs
- You must be 18 or older.
- Your BMI must be at least 30, or at least 27 with two or more conditions such as coronary heart disease, dyslipidemia, hypertension, sleep apnea, or type 2 diabetes.
- You must have documented failure of a weight-loss plan involving nutritional counseling, exercise, and calorie restriction within the past six months.
- You cannot be taking Ozempic, Victoza, or another GLP-1 drug at the same time.
- You cannot have a history of eating disorders, be pregnant or lactating, or have a malabsorption syndrome.
On top of that, fee-for-service rules updated in 2023 add step therapy: you have to try and fail a non-GLP-1 weight-loss drug in the six months before requesting a GLP-1, and your prescriber must attest that your obesity is “disability and life threatening.” Those rules push the BMI floor higher for GLP-1s specifically, to at least 40, or at least 35 with two or more chronic conditions.5Virginia DMAS. Upcoming Changes to Service Authorization Criteria for Weight Loss Drugs
Initial approval runs for three months. To renew for another six months, you have to show at least a 5% reduction in body weight from where you started. Coverage stops if your BMI drops below 24.3Virginia Medicaid Pharmacy Services. Service Authorization Form for Anti-Obesity Drugs
Managed care plans can set their own criteria. UnitedHealthcare’s Virginia Medicaid plan, for example, requires a BMI above 40 with no risk factors or above 37 with at least one risk factor, and expects you to have tried and failed a non-GLP-1 weight-loss medication first. It also covers members starting at age 12 and grants an initial authorization of six months rather than three.6UnitedHealthcare. Virginia Weight Loss Management Prior Authorization Form Read your own plan’s rules before assuming the fee-for-service criteria apply.
If Your Prescription Is Denied
The appeals path depends on how you get your Medicaid coverage. If you are in an MCO, you have to appeal through the plan’s internal process first. If the plan upholds the denial, you can then ask DMAS for a state-level review through its Appeals Information Management System (AIMS) portal. DMAS takes appeals questions at 804-371-8488 or appeals@dmas.virginia.gov.7Virginia DMAS. Appeals
Your plan’s pharmacy department can also process exception requests when a drug is off the formulary or when a restriction is blocking your prescription. UnitedHealthcare’s Virginia pharmacy line, as one example, is 1-800-310-6826.8UnitedHealthcare. Virginia Cardinal Care Preferred Drug List
Pending Changes to Watch
The rules could shift. In 2025, the Virginia General Assembly passed a budget provision (HB1600, Item 288) that would have broadened weight-loss drug coverage starting July 1, 2025, dropping the BMI threshold to 35, or above 30 with conditions such as hypertension, type 2 diabetes, or dyslipidemia. The provision set aside roughly $46.7 million for the first year.9Virginia Legislative Information System. HB1600 Budget Amendment Item 288 Governor Glenn Youngkin vetoed it, citing the “significant financial burden” of expanding GLP-1 access.10Virginia Legislative Information System. HB1600 Enrolled Governor Vetoes
A 2026 budget amendment (SB30, Item 291) directs DMAS to evaluate manufacturer programs, including the federal BALANCE demonstration model, to find the cheapest arrangement, with a target price of $245 or less per unit. If the BALANCE model wins out, DMAS would amend the state plan to cover weight-loss medications under specified BMI criteria; if another arrangement proves cheaper, DMAS can go that route instead.11Virginia Legislative Information System. SB30 Budget Amendment Item 291 Virginia has not finalized a decision, and the deadline for state applications to BALANCE is July 31, 2026.12KFF. What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid Several states that previously covered GLP-1s for obesity, including California, Pennsylvania, New Hampshire, and South Carolina, dropped that coverage in early 2026 under budget pressure.13The Guardian. States Medicaid Coverage of GLP-1 Drugs Virginia has kept the coverage for now, but the criteria and the program’s future are actively in play.