West Virginia

Weight-loss drugs are a listed non-covered service, and the manual says what that costs you. Section 518.3 provides that "The following list of drugs, drug products, and related services are not reimbursable," and among them: "Agents used for weight loss, anorexia, or weight gain, including binge-eating disorder." The same section closes with a sentence a denied member needs to read: "Non-covered services are not eligible for a Department of Human Services' (DoHS) Fair Hearing. See 42 § 431.220 When a hearing is required for more information." The chapter is stamped "Effective Date: 7/1/2024" on every page.

West Virginia Bureau for Medical Services, BMS Provider Manual, Chapter 518 Pharmacy Services, effective July 2024 · source

The drug list carries three classes for these drugs and names none of them for weight. Under "MAJOR ADVERSE CARDIOVASCULAR EVENT (MACE) REDUCTION AGENTS, GLP-1 AGONISTS" the entry is "WEGOVY INJECTION, TABLETS." Under "METABOLIC DYSFUNCTION-ASSOCIATED STEATOHEPATITIS (MASH)" the preferred agent is "WEGOVY*" and the non-preferred is "REZDIFFRA (resmetirom)*." Under "OBSTRUCTIVE SLEEP APNEA AGENTS" the sole preferred agent is "ZEPBOUND (tirzepatide)*," with the note "*Full PA criteria may be found on the PA Criteria page." The diabetes class is kept separate: "DIABETES AGENTS, GLP-1 AGONISTS" states that "Preferred agents may be authorized with a diagnosis of Diabetes Mellitus Type II" and lists OZEMPIC, TRULICITY and VICTOZA as preferred, with MOUNJARO and RYBELSUS non-preferred. The edition read is marked "Preferred Drug List and Prior Authorization Criteria Q2 v7 — Effective Date: 4/1/2026."

West Virginia Bureau for Medical Services, Office of Pharmacy Services, Preferred Drug List and Prior Authorization Criteria, effective April 2026 · source

The Wegovy criteria state the exclusion before they state a requirement: "Agents used for the purpose of weight loss are typically a benefit exclusion. Coverage of Wegovy will only be considered for the secondary prevention of a cardiovascular event and/or a diagnosis of MASH." The cardiovascular route needs "a documented Body Mass Index (BMI) of 27 kg/m2 or greater," a prescriber "with a clinical specialty certification/degree in cardiology, vascular surgery or neurology," and at least one of prior myocardial infarction, prior stroke, or symptomatic peripheral arterial disease shown by an "ankle-brachial systolic pressure index (ABI) of ≤ 0.85 at rest," a revascularization procedure, or an amputation. It also requires that the patient does NOT have "Type 1, type 2 diabetes" or an "HbA1c > 6.5%." "Initial approvals may be authorized for 90 days," and renewal requires "the patient to be taking an appropriate maintenance dose such as 1.7 mg or 2.4 mg per week." The MASH route needs stage 2 or stage 3 fibrosis confirmed by biopsy or elastography and a gastroenterologist or hepatologist. The document is headed "Effective 1/01/2026."

West Virginia Bureau for Medical Services, Office of Pharmacy Services, Prior Authorization Criteria — Wegovy (semaglutide), effective January 2026 · source

Zepbound gets the same opening sentence and one door. "Agents used for the purpose of weight loss are typically a benefit exclusion and not covered by West Virginia Medicaid. Coverage of Zepbound will only be considered for a diagnosis of OSA in adults with obesity." The criteria require "a diagnosis of moderate to severe OSA with a sleep study within the past twelve months confirming an apnea-hypopnea index (AHI) greater than or equal to fifteen events per hour," a "Body Mass Index (BMI) of 30 kg/m² or greater within the past three months," that the patient "has been prescribed or counseled on the use of continuous airway pressure (CPAP) as a potential therapy," and that a patient who also has type 2 diabetes has "been trialed on a preferred GLP-1 (indicated for Type II DM) compliantly for three months and experienced treatment failure." Reauthorization requires tolerance of "AT LEAST a 10 mg maintenance dose" and "a documented weight loss of > 5% or continued to maintain initial 5% weight loss." "Initial approvals may be authorized for 150 days" and "All fills will be limited to a 30-day supply." The document is headed "Effective 7/1/2025."

West Virginia Bureau for Medical Services, Office of Pharmacy Services, Prior Authorization Criteria — Zepbound (tirzepatide), effective July 2025 · source

There is one pharmacy answer in West Virginia, not one per plan. Section 518.15.2 states that "Medicaid members enrolled in the managed care organization plans receive pharmacy benefits from the fee-for-service (FFS) pharmacy program," and that "The FFS pharmacy program covers drugs which are submitted to pharmacies by written, telephonic, or electronic prescriptions." Drugs billed under J codes or HCPCS codes are the exception: those "are covered by the managed care programs and cannot be billed to the fee-for-service program at the point of sale." The same chapter sets out a prescriber-side appeal first — the prescriber "may appeal the decision to the Pharmacy Prior Authorization Vendor Appeals Department in writing (first level appeal)", appeals "will be processed within three business days," and "Any denial resulting from physician review is final," after which "The Medicaid member is notified of this denial and of the right to request a fair hearing."

West Virginia Bureau for Medical Services, BMS Provider Manual, Chapter 518 Pharmacy Services, effective July 2024 · source

West Virginia's hearing window is ninety days, and it does not run from the date on your letter. The rule that governs hearings held by the Board of Review provides: "The time limit for requesting a hearing shall be 90 days from the effective date of the action." A pre-hearing conference carries the same measure — "The time limit for requesting a pre-hearing conference shall be 90 days from the effective date of the adverse action" — and asking for either one before the action takes effect stops it: "If a current Recipient requests a hearing prior to the effective date of the adverse action then the adverse action shall be delayed pending a hearing decision." The manual also states how the count runs: "the day of the act, event, default, or omission from which the applicable period begins to run is not included," and a last day falling on a Saturday, Sunday or legal holiday runs to the next working day. Every page of the version read is marked "Rev. 8/22/2024."

West Virginia Office of Inspector General, Common Chapters Manual 710.16, Hearings Held by Board of Review, effective August 2024 · source