Wegovy Prior Authorization (Kentucky Medicaid)
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Rules for prior authorization of Wegovy for Kentucky Medicaid members managed by MedImpact, including restriction to a single Wegovy formulation per member and procedures when switching formulations.
The Commonwealth of Kentucky Department of Medicaid Services will allow only one Wegovy formulation per member.
If a member has an active PA for one Wegovy formulation and a prescriber requests a different formulation, the previously approved PA will be updated to the new formulation if approval criteria are met.
Renewal requests for the same formulation will follow the standard renewal criteria.
Coverage and Authorization Rules
Wegovy PA rules
Coverage is managed under prior authorization with a single-formulation restriction.
If a new PA request is submitted for a different Wegovy formulation, the previously approved PA will be updated to the new formulation only if the member meets the approval criteria.
Refer to MedImpact provider documents for full PA criteria and renewal requirements (https://kyportal.medimpact.com/provider-documents/drug-information).
The policy implicitly prohibits more than one active Wegovy formulation per member. Only one Wegovy formulation may be active for a Kentucky Medicaid member at a time; if a prescriber requests a different formulation, the previously approved prior authorization will be updated to the new formulation only if the member meets the approval criteria.
This document does not list the detailed clinical approval criteria. Clinical PA criteria for Wegovy are provided externally at the MedImpact provider documents site: https://kyportal.medimpact.com/provider-documents/drug-information.
Provider Submission Requirements & Impact
Wegovy prior authorization required; single-formulation rule
Wegovy requires prior authorization for Kentucky Medicaid members; only one Wegovy formulation is permitted per member. If a prescriber submits a new PA request for a different Wegovy formulation while a member has an active PA, the previously approved PA will be updated to the new formulation only if the member meets the approval criteria; renewal requests for the same formulation follow standard renewal criteria.
- PA criteria are available at: https://kyportal.medimpact.com/provider-documents/drug-information.
Single-formulation denial/update risk
Requests that would result in more than one active Wegovy formulation for a member may be denied or will trigger updating of the existing PA to the newly requested formulation only if approval criteria are met.
Submission and contact for PA
Submit prior authorization requests and direct inquiries through the MedImpact Kentucky pharmacy portal, by phone, or by fax using the program-specific contacts for the member’s plan. Use the listed Help Desk or Prior Authorization phone/fax numbers for assistance.
- MCO contacts: Pharmacy Help Desk (800) 210-7628 (24/7); Prior Authorizations phone (844) 336-2676 (8:00 AM–7:00 PM EST, 7 days/week); Fax (858) 357-2612; Portal: https://kyportal.medimpact.com/
- FFS contacts: Pharmacy Help Desk (877) 403-6034 (24/7); Prior Authorizations phone (877) 403-6034 (8:00 AM–7:00 PM EST, 7 days/week); Fax (858) 357-2612; Portal: https://kyportal.medimpact.com/
- Program questions: KYMCOPBM@MedImpact.com (MCO); KYMFFS@MedImpact.com (FFS)
- Plan billing BIN/PCN/GROUP values provided in source for pharmacy claims submission.
Single-formulation restriction and PA update behavior
If a new PA for a different Wegovy formulation is submitted while a member has an active PA, the existing PA will be updated to the requested formulation only when approval criteria are met; requests that would leave more than one formulation active may be denied.
- The Commonwealth of Kentucky DMS allows only one Wegovy formulation per member.
- When approval criteria are met, the previously approved PA will be changed to the new formulation rather than leaving both active.
Initial Authorization Criteria
Initial therapy
Covered when ALL of the following are met:
Full clinical approval criteria are available at the MedImpact provider documents URL.
Renewal and Continuation Criteria
Continuation/Renewal
Renewal for ongoing coverage:
Refer to https://kyportal.medimpact.com/provider-documents/drug-information for renewal documentation and requirements.
Policy Background
This policy governs administrative prior authorization handling of Wegovy (semaglutide) for Kentucky Medicaid members managed through MedImpact. It is effective January 10, 2026 and establishes that prior authorization is required and that only a single Wegovy formulation may be active per member. Renewal and full PA clinical criteria are referenced on the MedImpact provider documents URL.
Key Definitions
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