Colorado Medicaid GLP-1 Coverage 2026: Pattern #27 — Dual-Carve-Out Regulatory-Exclusion State (Wegovy CV BMI ≥ 25 Most Permissive in Series + Wegovy MASH + Zepbound OSA) + SB 25-048 Large-Group Commercial Mandate With Explicit Medicaid/CHP+ Carve-Out + MedImpact PBM Transition April 1 2026 + University of Colorado DUR Board

Colorado Medicaid — branded Health First Colorado, administered by the Department of Health Care Policy and Financing (HCPF) for approximately 1.2 million enrollees, with FFS pharmacy benefits now processed by MedImpact Healthcare Systems effective April 1, 2026 — is Pattern #27 in the 50-state Medicaid GLP-1 series: a dual-carve-out regulatory-exclusion state with three permanent positive-coverage FDA-label-restricted carve-outs, a PBM transition that took effect six weeks before this article, and the most politically distinctive GLP-1 legislative story in the series — a state that passed a commercial anti-obesity medication coverage mandate (SB 25-048) while deliberately excluding its own Medicaid program from that mandate.

The short answer for Health First Colorado members: GLP-1 medications are covered with prior authorization for three specific FDA-approved non-weight-loss indications, are $0 member copay when approved, and are not covered for chronic weight management — even though Colorado passed a law in 2025 that will require commercial insurers to offer anti-obesity medication coverage starting January 1, 2027.

TL;DR — What Health First Colorado covers, and what it does not

Health First Colorado DOES NOT cover GLP-1 receptor agonists for the chronic weight management FDA indication. The exclusion is anchored at four independent levels:

1. Federal permissive authority: 42 U.S.C. § 1396r-8(d)(2)(A) permits states to exclude “agents when used for anorexia, weight loss, or weight gain.”
2. State administrative rule: 10 CCR 2505-10 § 8.800.4.B.2.a excludes “Agents when used for anorexia or weight loss” from Medicaid pharmaceutical coverage.
3. Member-facing categorical exclusion: The Health First Colorado Pharmacy Benefits page states verbatim: “Health First Colorado does not cover the following categories of medications for any reason: … Weight-Loss Drugs …”
4. Operational PDL note: The April 1, 2026 PDL closes the GLP-1 class with the verbatim sentence: “Prior Authorization for GLP-1 analogues prescribed solely for weight loss will not be approved.”

Health First Colorado DOES cover GLP-1 receptor agonists, with prior authorization and $0 member copay (effective July 1, 2023), for these three FDA-approved non-weight-loss indications:

• Wegovy® (semaglutide injection AND oral tablet) — cardiovascular (CV) risk reduction: Age ≥ 18, established cardiovascular disease (history of MI, stroke, or symptomatic peripheral arterial disease), BMI ≥ 25 kg/m² (obesity or overweight), no T2DM diagnosis, prescribed to decrease CV-event risk, counseled on lifestyle interventions. BMI ≥ 25 is the most permissive Wegovy-CV threshold in the 27-state series (Washington and Oklahoma require BMI ≥ 27; Alabama similarly requires ≥ 27).
• Wegovy® (semaglutide injection only) — noncirrhotic MASH F2-F3 fibrosis: MASH confirmed by clinical presentation plus liver biopsy or imaging, age meets FDA-labeled minimum, no cirrhosis or significant non-MASH liver disease, prescribed for FDA-labeled indication, prescribed by or in consultation with a gastroenterologist, endocrinologist, obesity medicine specialist, hepatologist, or liver transplant provider. FDA approved Wegovy for MASH in December 2025.
• Zepbound® (tirzepatide) — moderate-to-severe obstructive sleep apnea (OSA): Age ≥ 18, documented moderate-to-severe OSA diagnosis, BMI ≥ 30 kg/m², OSA confirmed by FDA-approved sleep test, baseline polysomnogram with AHI ≥ 15 events/hour, not pregnant or planning pregnancy, counseled on MTC risk (no personal/family history of MTC or MEN 2), prescribed by or in consultation with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist, counseled on lifestyle interventions, AND failed 6-month CPAP trial OR contraindication to PAP therapy. Maximum dose 15 mg subcutaneously once weekly.

Health First Colorado covers GLP-1s for type 2 diabetes mellitus (T2DM) through the standard diabetic-agent preferred drug tier. Preferred T2DM agents (May 2026 PDL): liraglutide pen (Teva), Ozempic pen, Trulicity pen, Mounjaro pen, Victoza pen, and Wegovy pen/tablet (CV-indication-only tier).

Health First Colorado does NOT cover: Saxenda, Foundayo (orforglipron), Qsymia, Contrave, phentermine, orlistat, Xenical, Imcivree (setmelanotide), or benzphetamine — none appear on the PDL and none have DUR-Board-approved PA criteria.

SB 25-048 (signed June 3, 2025; effective January 1, 2027) mandates that large-group commercial health plans in Colorado offer anti-obesity medication coverage — but Section 4 of the enrolled bill expressly excludes CHP+, and Health First Colorado is excluded by the Title 10/Title 25.5 scope of the operative mandate.

Operational PBM identity (as of 2026-05-10): MedImpact Healthcare Systems, Inc. — effective April 1, 2026 (formerly Prime Therapeutics, which acquired Magellan Rx in 2022). Pharmacy Help Desk: 888-672-7203. Email: COFFSTeams@medimpact.com. BIN/PCN/Group: unchanged from the Prime transition.

The 10 CCR 2505-10 § 8.800.4.B.2.a categorical exclusion

Colorado's Medicaid pharmaceutical benefit is governed by Title 10 of the Colorado Code of Regulations, Chapter 2505-10 (Medical Assistance), Section 8.800 (Pharmaceuticals, Podiatry Services, Immunization Services). The Medical Services Board (MSB) is the rulemaking body; amendment requires a formal MSB rulemaking docket under the Colorado Administrative Procedures Act.

The canonical exclusion is at subsection (4)(B)(2)(a). The full subsection (4)(B) text, verified by direct curl from the Colorado Secretary of State CCR database (ruleVersionId 8828) and cross-verified at Cornell LII:

“8.800.4.B. Pursuant to 42 U.S.C. 1396r-8 (d)(2), certain drugs or classes of drugs may be excluded from coverage or may be subject to restrictions.

1. The following are covered with restrictions:

a. Agents when used for weight gain;

b. Agents when used for the symptomatic relief of cough and colds;

c. Prescription vitamin and mineral products, except prenatal vitamins and fluoride, for documented deficiency; and

d. Non-prescription Drugs.

2. The following are excluded from coverage:

a. Agents when used for anorexia or weight loss;

b. Agents when used to promote fertility;

c. Covered outpatient drugs that the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee; and

d. Agents used for the treatment of sexual or erectile dysfunction unless such agents are used to treat a condition, other than a sexual or erectile dysfunction, for which the agents have been approved by the FDA.”

The federal floor is 42 U.S.C. § 1396r-8(d)(2)(A):

“(2) Excludable drugs. The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.”

Note that Colorado's CCR at § 8.800.4.E explicitly incorporates 42 U.S.C. § 1396r-8(d)(2014) by reference — locking in the federal floor as of the 2014 amendment and “exclud[ing] later amendments to or editions of the referenced material.” This is a structurally distinctive citation discipline among the 27-state series: the MSB has anchored its exclusion regime at a specific historical version of federal law.

How the carve-outs coexist with the categorical exclusion

The three positive carve-outs — Wegovy CV, Wegovy MASH, Zepbound OSA — are NOT based on a textual exception written into § 8.800.4.B.2.a. They are based on a regulatory re-characterization: when Wegovy is prescribed for MACE risk reduction, it is classified as a cardiovascular drug, not a weight-loss drug. When Zepbound is prescribed for OSA, it is classified as a sleep apnea drug, not a weight-loss drug. This re-characterization flows from the FDA-approved non-weight-loss indications and is operationalized through the PDL's indication-scoped PA criteria.

The operative PDL sentence that operationalizes this logic is:

“Note: Prior Authorization for GLP-1 analogues prescribed solely for weight loss will not be approved.”

The word “solely” is doing significant operational work. Colorado's exclusion mechanism is “is this prescription solely for weight loss?” — not “does this drug have any weight-loss intent?” A Wegovy prescription justified primarily for CV risk reduction (with weight loss as a secondary effect) qualifies for the CV carve-out. The member-facing pharmacy benefits page lists “Weight-Loss Drugs” as a categorical non-coverage category “for any reason” — but that plain-language formulation is operationally narrower than it appears, because the DUR-Board-approved carve-outs establish that Wegovy/Zepbound uses for CV/MASH/OSA are NOT classified as weight-loss uses for purposes of the exclusion.

This architecture is structurally similar to Oklahoma SoonerCare (Pattern #24) — which also has a categorical regulatory exclusion at OAC 317:30-5-72.1(1)(D) plus three DUR-Board-approved FDA-label carve-outs — and to Washington Apple Health (Pattern #14) — which has WAC 182-530-2100(1)(b)(i) as its regulatory anchor and covers the same triple-indication set (Wegovy CV + Wegovy MASH + Zepbound OSA) through indication-scoped PA criteria. Colorado's distinctiveness within this cluster is: (1) the most permissive BMI threshold (BMI ≥ 25) in the series for the Wegovy CV pathway; (2) the Wegovy oral tablet PDL entry (shared only with Washington in the 27-state series); and (3) the SB 25-048 commercial mandate with explicit Medicaid carve-out.

Wegovy CV (semaglutide): BMI ≥ 25 kg/m² — the most permissive threshold in the 27-state series

The April 1, 2026 PDL V1.1 lists Wegovy (semaglutide) pen and tablet as a preferred entry in the GLP-1 Receptor Agonists class, denoted with a double-asterisk (**) indicating it has specific non-T2DM criteria. The verbatim PA criteria from the PDL:

“WEGOVY (semaglutide) may be approved if meeting the following criteria:

• Member is 18 years of age or older AND
• Member has established cardiovascular disease (history of myocardial infarction, stroke, or symptomatic peripheral arterial disease) and either obesity or overweight (defined as a BMI ≥ 25 kg/m²) AND
• Member does not have a diagnosis of Type 2 diabetes AND
• Wegovy (semaglutide) is being prescribed to decrease the risk of adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) AND
• Member has been counseled regarding implementation of lifestyle interventions (diet modification and exercise) to promote weight loss.”

The BMI ≥ 25 kg/m² threshold is the most permissive in the 27-state series. For comparison:

• Washington (Pattern #14): BMI ≥ 27 for Wegovy CV (HCA Medical Policy 61.25.20.AA-4)
• Oklahoma (Pattern #24): BMI ≥ 27 for Wegovy CV (OHCA DUR Recommendation 5, October 2024)
• Alabama (Pattern #23): BMI ≥ 27 for Wegovy MACE (PA Form 369 Cardiac Agents section)
• Colorado (Pattern #27): BMI ≥ 25 — matching the FDA Wegovy SELECT MACE trial population definition of “obesity or overweight” more precisely than the BMI ≥ 27 threshold used by its peer states

This matters operationally. A Health First Colorado member with BMI 26.5 (overweight), a prior myocardial infarction, and no T2DM may qualify for Wegovy under the CV carve-out in Colorado — but the same member would not qualify in Washington, Oklahoma, or Alabama, where the BMI floor is 27. The Colorado DUR Board adopted the BMI ≥ 25 threshold at its August 12, 2025 meeting.

The August 12, 2025 DUR Board Minutes document the formal adoption vote:

“T Brubaker moved to accept the criteria as amended. Seconded by I Pan. Motion passed unanimously.”

One operational note: the T2DM exclusion is strict. A member with both established CVD and T2DM does not qualify for the Wegovy CV carve-out. For such a member, Wegovy or Ozempic coverage is available through the standard T2DM preferred-drug tier — not through the CV carve-out pathway.

Wegovy MASH: December 2025 FDA approval reflected in the April 2026 PDL

The FDA approved Wegovy (semaglutide injection) for the treatment of metabolic dysfunction-associated steatohepatitis (MASH) with moderate-to-advanced fibrosis in December 2025. The Health First Colorado DUR Board adopted the MASH criteria at the same August 12, 2025 meeting as the CV criteria (anticipating the FDA approval), and the criteria are reflected in the April 1, 2026 PDL V1.1.

Verbatim PDL criteria for the MASH indication:

“Requests for GLP-1 analogues that are FDA-indicated for the treatment of metabolic dysfunction-associated steatohepatitis (MASH) may be approved if meeting the following:

• Member has a diagnosis of MASH with stage F2 to F3 fibrosis that has been confirmed by clinical presentation along with liver biopsy or imaging results AND
• Member meets the FDA-labeled minimum age requirement for the prescribed product AND
• Member does not have cirrhosis or significant liver disease other than MASH AND
• The requested medication is being prescribed for use for the FDA-labeled indication and as outlined in product package labeling AND
• Medication is prescribed by or in consultation with a gastroenterologist, endocrinologist, obesity medicine specialist, hepatologist, or liver transplant provider AND
• Requests for non-preferred agents will be subject to meeting non-preferred criteria listed below.”

Note that only Wegovy semaglutide injection carries the MASH FDA indication. The oral tablet formulation (Rybelsus/Wegovy tablet) does not carry the MASH indication; the MASH criteria apply to injection only. A member with MASH who prefers oral semaglutide would need to qualify through the Wegovy CV indication — which requires established CVD, not MASH.

The earlier DUR Board draft (August 12, 2025 minutes) of the MASH criteria required liver biopsy only; the April 1, 2026 PDL softened this to “liver biopsy or imaging results,” making the pathway more accessible for members who have undergone non-invasive imaging-based fibrosis staging. The Colorado MASH pathway does not enumerate specific imaging modalities (unlike Washington's policy, which explicitly lists Fib-4, FibroScan, APRI, FibroTest, ARFI/PSWE, and elastography). This leaves some discretion to the reviewing pharmacist; members should ensure their prescriber documents the specific imaging modality used to stage fibrosis.

Zepbound OSA: tirzepatide for moderate-to-severe obstructive sleep apnea

Zepbound (tirzepatide) appears as a non-preferred entry in the Colorado GLP-1 class — PA required, specific criteria apply. The April 1, 2026 PDL V1.1 verbatim OSA criteria (incorporating the November 4, 2025 DUR Board refinements):

“ZEPBOUND (tirzepatide) may be approved if meeting the following criteria:

• Member is 18 years of age or older AND
• Member has a documented diagnosis of moderate to severe obstructive sleep apnea (OSA) AND
• Member has a BMI ≥ 30 kg/m² indicating obesity documented in medical chart notes AND
• Diagnosis of OSA is confirmed by a sleep test that is approved by the Food and Drug Administration (FDA) as a diagnostic device AND
• A polysomnogram has been performed at baseline with a documented result of Apnea-Hypopnea Index (AHI) ≥ 15 events/hour (submission of sleep study documentation required) AND
• Member is not pregnant or planning to become pregnant AND
• Member has been counseled regarding the risk of medullary thyroid cancer (MTC) with the use of Zepbound (tirzepatide) and does not have a personal or family history of MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) AND
• The requested medication is being prescribed by or in consultation with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist AND
• Member has been counseled regarding and is engaged in implementation of lifestyle interventions (diet modification and exercise) to promote weight loss AND
• Member has failed a 6-month trial of continuous positive airway pressure (CPAP) or has a contraindication to the use of PAP therapy.”

Verbatim reauthorization criteria (1-year renewal):

“Reauthorization: Reauthorization for one year may be approved if meeting the following criteria:

• Member has previous PA approval on file (requests for members that do not have a historic PA approval on file will be subject to meeting ‘Initial Authorization’ criteria listed above) AND
• Prescriber attests that an in-person clinical re-evaluation of OSA from baseline has been performed by the treating practitioner AND
• Clinical improvement in OSA symptoms has been documented in clinical chart notes AND
• Adherence to use of Zepbound (tirzepatide) regimen has been evaluated by the treating practitioner.”

Key clinical distinctions for OSA vs. CV pathway:

• Zepbound OSA requires BMI ≥ 30 (obesity), not merely overweight. A member with BMI 27 may qualify for Wegovy CV but does not qualify for Zepbound OSA.
• Zepbound OSA requires a documented failed 6-month CPAP trial or documented contraindication to PAP therapy. This step-therapy requirement applies; CPAP must be tried first unless contraindicated.
• The maximum dose is 15 mg subcutaneously once weekly.
• The November 4, 2025 DUR Board refinement added criterion 4 (“confirmed by a sleep test that is approved by the FDA as a diagnostic device”) — mirroring the FDA Zepbound OSA label language and requiring that the sleep-testing device itself carry FDA clearance as a diagnostic device.

The November 4, 2025 DUR Board vote record:

“Discussion — No Board members reported a potential conflict of interest for the GLP-1 analogues class. S Klocke moved to accept the criteria as written. Seconded by T Brubaker. Motion passed with six votes in favor. B Jackson abstained, as he had to leave the meeting for another obligation.”

Wegovy oral tablet — December 2025 FDA approval: Colorado and Washington are the only two states in the 27-state series with this PDL entry

The FDA approved an oral tablet formulation of semaglutide (branded Wegovy tablet, distinct from Rybelsus which is semaglutide oral for T2DM) in December 2025 for the cardiovascular risk reduction indication. The April 1, 2026 Colorado PDL V1.1 includes the Wegovy oral tablet as part of the preferred “WEGOVY (semaglutide) pen, tablet” entry under the CV-indication-only tier (**).

The PDL verbatim header for this entry:

“**WEGOVY (semaglutide) pen, tablet”

[** = preferred, CV-indication-only PA criteria apply]

Among the 27 states in this series as of 2026-05-10, only Colorado and Washington have explicitly listed the Wegovy oral tablet formulation as a PDL entry with indication-scoped PA criteria. Washington's HCA Medical Policy 61.25.20.AA-4 (effective 2/1/2026, Version 4 of 4) explicitly added the Wegovy tablet in its February 2026 update.

The practical implication: a Health First Colorado member who has established CVD, no T2DM, and BMI ≥ 25 may request either Wegovy injection or Wegovy oral tablet under the CV-indication criteria. The oral formulation may be preferred by members who have injection aversion or other barriers to self-injection. The MASH carve-out, however, applies to the injection formulation only — the MASH FDA indication does not extend to the oral tablet.

PBM transition: Prime Therapeutics → MedImpact Healthcare Systems (April 1, 2026)

The most significant operational change to Health First Colorado's pharmacy administration in 2026 occurred six weeks before this article: on April 1, 2026, the FFS pharmacy benefit manager transitioned from Prime Therapeutics to MedImpact Healthcare Systems, Inc.

Verbatim from the HCPF “Fee-For-Service Pharmacy Benefit Manager (PBM) Change Notification – 04-01-2026”:

“Dear Pharmacy Provider,

Effective at 12:00 a.m. ET, April 1, 2026, Health First Colorado Fee-for-Service (FFS) pharmacy claims processing and prior authorization review transitioned to MedImpact Healthcare Systems, Inc. Contact the MedImpact Pharmacy Help Desk at 888-672-7203.

Note: There are no changes to the Bank Identification Number (BIN), Processor Control Number (PCN) and Group. Contact the switch vendor to confirm that claims are being routed correctly to MedImpact on or after April 1, 2026. Contact MedImpact at COFFSTeams@medimpact.com for further assistance.”

Verbatim provider network continuity language from the same document:

“Provider Network: Provider Enrollment in the Health First Colorado FFS program has not changed. Pharmacies do not need to reenroll as MedImpact will continue using Colorado's existing pharmacy network.”

Verbatim PDL continuity language:

“Preferred Drug List (PDL): All existing PDL limits and requirements remain in effect. A copy of the PDL is available on the Pharmacy Resources web page.”

Operational notes for prescribers and pharmacists:

• Pharmacy Help Desk: 888-672-7203 (same number previously associated with Prime Therapeutics; operationally continuous through the cutover)
• MedImpact email: COFFSTeams@medimpact.com
• No BIN/PCN/Group change — pharmacies experienced a seamless transition at point of sale
• PA forms: Updated to reflect MedImpact contact information; available on the HCPF Pharmacy Resources page
• Claims reversal: B3 Claim Rebill is not supported by MedImpact; claims requiring adjustment must be reversed and resubmitted as new claims
• Older references to “Magellan Rx” or “Prime Therapeutics” as Colorado's PBM are pre-April 1, 2026 materials. MedImpact is the current FFS PBM as of 2026-05-10.

Important distinction: ColoradoPAR, administered by Acentra Health (formerly Kepro), handles FFS utilization management for outpatient benefits, services, supplies, out-of-state inpatient hospital services, and select Physician-Administered Drugs (PADs) — but NOT outpatient pharmacy. GLP-1 pharmacy PA requests go to the MedImpact Pharmacy Help Desk (888-672-7203), not to ColoradoPAR/Acentra. This is a frequent source of prescriber confusion.

The four RAEs + one MCO under ACC Phase III (effective July 1, 2025)

Health First Colorado care delivery is organized through the Accountable Care Collaborative (ACC) Phase III, launched July 1, 2025. Verbatim from the HCPF ACC Phase III page:

“About ACC Phase III. The Department of Health Care Policy and Financing (HCPF) administers Health First Colorado (Colorado's Medicaid program) and other health care programs for Coloradans who qualify. Created in 2011, the ACC is the primary delivery system for Health First Colorado. Regional Accountable Entities (RAEs) are responsible for promoting member health and well-being by administering the capitated behavioral health benefit, establishing and supporting networks of providers and coordinating medical and community-based services for members in their region. Two physical health managed care capitation plans, referred to as Managed Care Organizations (MCOs), deliver physical health care in certain areas of the state. New contracts with RAEs and MCOs, ACC Phase III, launched July 1, 2025.”

The four RAEs and one MCO, with their verbatim contact details from the HCPF page:

RAEs do NOT administer outpatient pharmacy benefits. This is a critical point for members navigating the system. The RAEs (Rocky Mountain Health Plans, Northeast Health Partners, Colorado Community Health Alliance, Colorado Access) administer the capitated behavioral health benefit and care coordination. The Elevate (Denver Health) MCO administers physical health for its enrolled members in the Denver area. But for all five entities, outpatient pharmacy benefits — including Wegovy/Zepbound PA decisions — flow through the FFS pharmacy program administered by MedImpact.

If a Health First Colorado member has a question about Wegovy or Zepbound prior authorization, the correct contact is Colorado Pharmacy Call Center: 888-672-7203 (administered by MedImpact effective April 1, 2026), not the RAE helpline. The RAE may be helpful for coordinating specialist referrals required by the carve-out criteria (e.g., cardiology for Wegovy CV, sleep medicine for Zepbound OSA) — but the PA itself is adjudicated by MedImpact.

Members in all five RAE/MCO regions operate under the same HCPF PDL and the same DUR-Board-approved PA criteria. There is no regional variation in Wegovy or Zepbound coverage under Health First Colorado.

DUR Board: University of Colorado Skaggs School of Pharmacy — unique academic governance in the 27-state series

Health First Colorado's Drug Utilization Review (DUR) Board is administered through a contract relationship with the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) at the CU Anschutz Medical Campus in Aurora, Colorado. The program contact email is SSPPS.co-dur@cuanschutz.edu.

The DUR Board has 8 members (4 physicians + 4 pharmacists) appointed by the HCPF Executive Director. The Board meets quarterly in virtual Zoom format: February, May, August, and November, typically 1:00 p.m.–5:00 p.m. Mountain Time. Program administrators are Jeffrey Taylor and Julia Rawlings in the HCPF Pharmacy Section. DUR Board fax: 303-866-3590.

Among the 27 states in this series, Colorado's DUR governance is distinctive for its academic affiliation. The closest analog is Oklahoma (Pattern #24), where the OHCA DUR Board operates in partnership with the University of Oklahoma College of Pharmacy / Pharmacy Management Consultants (PMC) — but Oklahoma's university role extends to actual PA-criteria drafting and adjudication. Colorado's university role is limited to DUR Board governance and academic affiliation; the PA adjudication itself is administered by MedImpact.

The August 12, 2025 DUR Board minutes document J. Taylor's key clarification on the EPSDT pediatric pathway — which is the only pathway through which pediatric members under age 21 may access GLP-1s for off-label chronic weight management:

“Dr. Taylor noted that criteria presented on the PDL is based on FDA labeling. The Department receives case-by-case exception requests for off-label medical necessity scenarios through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit that includes children and adolescents under age 21 years. Dr. Taylor clarified that while there have been cases in which coverage was opened up to the pediatric population for off-label indications, a substantial amount of evidence is necessary — by Medicaid rule — to support those case-by-case requests.”

The DUR Board also considered — and voted unanimously to pass — a motion requesting that HCPF reevaluate the criteria to allow off-label GLP-1 use in the pediatric population in consultation with a pediatric endocrinologist or pediatric nutrition medicine physician. However, this motion was routed through the case-by-case EPSDT pathway; no class-coverage rule for pediatric GLP-1 chronic weight management was enacted. The EPSDT pathway is narrow and requires substantial individual medical-necessity evidence.

SB 25-048: the commercial mandate with explicit Medicaid carve-out

The most editorially distinctive fact about Colorado in the 27-state series is SB 25-048: the state that passed a commercial anti-obesity medication coverage mandate while deliberately excluding its own Medicaid program. No other state in the 27-state series has executed this exact split-track legislative strategy.

Bill metadata

• Title: Diabetes Prevention and Obesity Treatment Act
• Signed: Governor Jared Polis, June 3, 2025
• Session Law: Chapter 365
• Effective Date: January 1, 2027 (subject to referendum petition contingency)
• Senate passage: 26-9 and 27-8, April 30, 2025
• House passage: 24-0, May 6, 2025

Section 3: the large-group commercial coverage mandate

Verbatim from the enrolled bill text:

“SECTION 3. In Colorado Revised Statutes, 10-16-104, add (29) as follows:

10-16-104. Mandatory coverage provisions — applicability — rules — definitions. (29) Treatment for obesity and pre-diabetes. (a) ALL LARGE GROUP HEALTH BENEFIT PLANS ISSUED OR RENEWED IN THIS STATE MUST PROVIDE COVERAGE FOR THE TREATMENT OF THE CHRONIC DISEASE OF OBESITY AND THE TREATMENT OF PRE-DIABETES, INCLUDING COVERAGE FOR A COMPARABLE PROGRAM TO THE NATIONAL DIABETES PREVENTION PROGRAM, MEDICAL NUTRITION THERAPY, INTENSIVE BEHAVIORAL OR LIFESTYLE THERAPY, AND METABOLIC AND BARIATRIC SURGERY.

(b) FOR A LARGE GROUP HEALTH BENEFIT PLAN OFFERED IN THIS STATE, A CARRIER SHALL OFFER THE POLICYHOLDER THE OPTION TO PURCHASE COVERAGE FOR FDA-APPROVED ANTI-OBESITY MEDICATIONS, INCLUDING AT LEAST ONE FDA-APPROVED GLP-1 MEDICATION. THIS SUBSECTION (29) DOES NOT REQUIRE A CARRIER TO OFFER COVERAGE FOR WHICH PREMIUMS WOULD NOT COVER EXPECTED BENEFITS.”

Section 4: the express CHP+ exclusion (and Health First Colorado's exclusion by Title 10/25.5 scope)

Verbatim from the enrolled bill, Section 4:

“SECTION 4. In Colorado Revised Statutes, 25.5-8-107, add (1)(a)(VII) as follows:

25.5-8-107. Duties of the department — schedule of services — premiums — copayments — subsidies — purchase of childhood immunizations. (1) In addition to any other duties pursuant to this article 8, the department has the following duties:

(a) (VII) THE SCHEDULE OF HEALTH-CARE SERVICES INCLUDED IN THE PLAN MUST NOT INCLUDE COVERAGE PURSUANT TO THE MANDATORY COVERAGE PROVISIONS OF SECTION 10-16-104 (29).”

The Section 4 language amends C.R.S. § 25.5-8-107, which governs CHP+ (the Child Health Plan Plus). It expressly prohibits the CHP+ schedule of services from including coverage under the Section 3 mandate.

Health First Colorado (Medicaid) is excluded by a different mechanism: the Section 3 mandate applies to “ALL LARGE GROUP HEALTH BENEFIT PLANS ISSUED OR RENEWED IN THIS STATE” — which by C.R.S. Title 10, Article 16 definitions does not include Health First Colorado. Medicaid is governed under C.R.S. Title 25.5, Article 5 and is administratively outside the Title 10 commercial health insurance framework. The mandate is therefore inapplicable to Medicaid by definitional scope, not by express exclusion.

The fiscal note story

The original draft of SB 25-048 included a Medicaid coverage mandate. The Colorado Legislative Council Staff fiscal note (as introduced) projected the following Medicaid costs if the mandate extended to Health First Colorado:

• FY 2025-26: $71.7 million (estimated 18,000 Medicaid clients)
• FY 2026-27: $134.2 million (estimated 26,000 Medicaid clients)
• FY 2027-28: $122.9 million (estimated at approximately $500/client/month after rebates)

These Medicaid mandate costs were deemed politically untenable and were stripped from the final enrolled bill before passage. The 2025 enacted version of SB 25-048 represents the legislative compromise: commercial mandate yes, Medicaid mandate no. The predecessor bill (SB 24-054, introduced in 2024 with the Medicaid mandate included) failed entirely.

What SB 25-048 means for Colorado workers

Effective January 1, 2027 (subject to petition contingency):

• Large-group commercial plans (employer-sponsored plans with large-group designation under Colorado law) must provide coverage for obesity and pre-diabetes treatment including medical nutrition therapy, intensive behavioral/lifestyle therapy, and bariatric surgery.
• Large-group carriers must offer policyholders the option to purchase coverage for at least one FDA-approved GLP-1 medication for anti-obesity use.
• The “premiums would not cover expected benefits” carve-out (Section 3(29)(b)) allows carriers to decline offering anti-obesity medication coverage if actuarially unsustainable — a substantial operational backdoor.
• Health First Colorado members are not affected by SB 25-048. The bill does not mandate, and does not create, any new Medicaid coverage for anti-obesity medications.

The Colorado comparison to peer states on this dimension: New Jersey (Pattern #11) has active reversal-direction legislation (A3369) that would mandate Medicaid coverage but has not passed. Kentucky (Pattern #21) is the inverse: the Beshear administration proposed a regulatory amendment to extend coverage to Kentucky Medicaid, and the legislature overrode it via SB 65. Colorado is a third structural variant: the legislature passed a mandate but carefully scoped it to exclude Medicaid in the same bill.

State employee plan: Colorado DPA eliminated GLP-1 weight-loss coverage July 1, 2025 (distinct from Health First Colorado)

Effective July 1, 2025, the Colorado Department of Personnel & Administration (DPA) removed coverage of GLP-1 medications for weight loss under state employee health plans. Employees who were actively taking GLP-1s for weight loss as of June 30, 2025 were grandfathered into coverage with a per-prescription copay increase from $30 to $120. Estimated annual savings to the state: approximately $17 million.

This change applies to the Colorado state employee health plan, which is governed by the Department of Personnel & Administration — NOT to Health First Colorado (Medicaid). State employees who are also Medicaid-eligible (a small minority) have separate coverage determinations under their Medicaid eligibility. The vast majority of Colorado state employees are not on Health First Colorado and are not subject to Health First Colorado coverage rules. The DPA decision does not change the Health First Colorado PDL, the DUR Board criteria, or the 10 CCR 2505-10 § 8.800.4.B.2.a regulatory exclusion.

The state-employee-plan change occurred approximately one month before Governor Polis signed SB 25-048 (June 3, 2025). These are separate policy tracks with separate legal authority. The SB 25-048 commercial mandate (effective January 1, 2027) does not apply to state employee plans, which are governed under a different statutory framework.

Appeals: state fair hearings via the Office of Administrative Courts

A Health First Colorado member who receives a Notice of Action denying coverage for Wegovy, Zepbound, or any other medication has the following appeals pathway:

Step 1: Understand the denial

The Notice of Action will specify the criterion the member did not meet (e.g., “No documentation of established CVD” or “BMI not documented at or above 25 kg/m²”). Request the written denial letter and the specific verbatim PDL criterion cited. This is the document your prescriber will need to address.

Step 2: Provider resubmission

Your provider can resubmit the PA with updated documentation addressing the criterion that was not met. Per the Health First Colorado Pharmacy Benefits page:

“If the criteria are not met, the doctor can re-submit with updated information, or appeal the decision to Health First Colorado's Pharmacy Benefits section for further review.”

Step 3: State fair hearing via the Office of Administrative Courts (OAC)

• Filing deadline: 60 days from the date of the Notice of Action
• How to file: Submit a Request for State Level Hearing form to the OAC, or write a letter to OAC requesting a hearing, or call OAC at (303) 866-5626
• OAC address: 1525 Sherman St., 4th Floor, Denver, CO 80203
• Hearing process: OAC schedules a hearing; an Administrative Law Judge (ALJ) hears the case and prepares an Initial Decision based on evidence, document review, and applicable laws
• Continuation of services: If the appeal is filed within 10 days of the Notice of Action AND services are currently being received, the member may request that benefits continue pending the appeal decision

Emergency supply

The Health First Colorado Pharmacy Benefits page states verbatim:

“If you have an emergency, your provider can get a 72-hour emergency supply of the drug you need.”

This is important for members with urgent T2DM needs who experience a coverage gap during a PA review.

Practical prognosis for Wegovy/Zepbound appeals

Appeals are most likely to succeed when there is a procedural error in the initial denial (criteria were not properly evaluated against the submitted documentation) or when the member's clinical situation meets criteria that were not properly considered (e.g., established CVD with prior MI documented in the medical record but not included in the initial PA submission). A denial for the weight-loss-only indication will be sustained on appeal because the § 8.800.4.B.2.a exclusion and the PDL note are clear and binding. For more general guidance on GLP-1 denial appeals, see our GLP-1 insurance dropped coverage appeal playbook, which now includes the Colorado state fair hearing pathway.

How Colorado compares: Washington, Oklahoma, and Alabama as the closest analogues

Colorado is Pattern #27 in the 50-state Medicaid GLP-1 series — the 27th of 27 states fully documented across 27 distinct coverage patterns. The three closest structural analogues are:

Washington Apple Health (Pattern #14) — closest triple-carve-out analog

Washington Apple Health is the closest structural analog to Colorado on the triple-carve-out architecture (Wegovy CV + Wegovy MASH + Zepbound OSA). Both states have the same three FDA-label-restricted carve-outs. Both states list the Wegovy oral tablet as a PDL entry. Key differences:

• BMI threshold: WA requires BMI ≥ 27 for Wegovy CV; CO requires BMI ≥ 25. Colorado is more permissive.
• KFF classification: WA appears on the KFF January 2026 “13 covering states” list; CO does not. Both states have the same carve-out structure but KFF classifies them differently — this is the YMYL trap for Washington documented in Pattern #14. Colorado is unambiguously NOT a KFF-classified covering state.
• Commercial mandate: WA's SB 5353/HB 1326 (commercial anti-obesity mandate) has been retained in committee multiple sessions; CO's SB 25-048 was enacted June 2025. Colorado is ahead of Washington on the commercial mandate track.
• PBM: WA uses the Apple Health PDL with Prime Therapeutics as the P&T/DUR clinical-class consultant; CO transitioned to MedImpact April 1, 2026.

Oklahoma SoonerCare (Pattern #24) — closest regulatory-exclusion + university-DUR analog

Oklahoma SoonerCare is the closest structural analog on the “categorical state administrative code exclusion + three DUR-Board-approved FDA-label carve-outs + university pharmacy affiliation” architecture. Key differences:

• BMI threshold: OK requires BMI ≥ 27 for Wegovy CV; CO requires BMI ≥ 25.
• Imcivree: OK has a DUR-Board-approved Imcivree (setmelanotide) monogenic-obesity carve-out (unique in the 27-state series). CO does NOT have Imcivree on its PDL.
• University PA role: OK's OU College of Pharmacy / PMC drafts and adjudicates PA criteria. CO's University of Colorado SSPPS governs the DUR Board academically but does not adjudicate PAs — MedImpact adjudicates.
• OK-specific approval rate: June 2025 SoonerCare FFS approval rate was 7.8% (8 of 102 Anti-Obesity Agent PA requests). Colorado does not publish a comparable quarterly approval-rate statistic.

Alabama Medicaid (Pattern #23) — closest two-carve-out analog

Alabama has the Zepbound OSA-only PDL carve-out and the Wegovy MACE-only PA carve-out, but lacks the MASH carve-out that Colorado has. Colorado's triple-carve-out is more permissive. Other structural similarities: both states have a categorical state administrative code exclusion (CO at § 8.800.4.B.2.a; AL at Ala. Admin. Code r. 560-X-16-.01(2)(b)); both have non-expansion state status removed from the comparison (Alabama is a non-expansion state; Colorado expanded Medicaid January 1, 2014).

The KFF classification note

The Colorado Legislative Council Staff GLP-1 Landscape Memo (February 16, 2026) identifies the 13 KFF-classified covering states as of January 2026: Delaware, Kansas, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, North Carolina, Rhode Island, Tennessee, Utah, Virginia, and Wisconsin. Colorado is not on this list. Colorado has three FDA-label-restricted carve-outs but does not have general chronic-weight-management coverage — the defining criterion for KFF's classification.

What Health First Colorado members can do in 2026

If you have established cardiovascular disease and no T2DM (Wegovy CV pathway)

1. Document your CVD history: Your prescriber needs documented evidence of prior myocardial infarction, stroke, or symptomatic peripheral arterial disease. Hospital discharge summaries, cardiology notes, or diagnostic reports confirming MI/stroke/symptomatic PAD are the evidence base.
2. Confirm BMI ≥ 25: BMI must be documented in chart notes. Colorado's BMI ≥ 25 threshold is the most accessible in the series — a member who is overweight (not obese) qualifies.
3. Confirm no T2DM diagnosis: The Wegovy CV criteria explicitly exclude members with a T2DM diagnosis. If you have T2DM, you may still access Wegovy through the T2DM preferred-drug tier.
4. Ask about the oral tablet option: If you prefer not to inject, ask your prescriber about Wegovy oral tablet — which is now listed on the Colorado PDL under the same CV-indication criteria. Note: the oral tablet does not carry the MASH indication.
5. Submit PA to MedImpact: Call the Colorado Pharmacy Call Center at 888-672-7203 or use the ePA system through your prescriber's EHR. PA decisions are processed within 24 hours; most phone requests are decided immediately. Emergency 72-hour supply available if needed.

If you have noncirrhotic MASH F2-F3 fibrosis (Wegovy MASH pathway)

1. Obtain imaging or biopsy confirmation: The MASH criteria require “clinical presentation along with liver biopsy or imaging results” documenting stage F2-F3 fibrosis. Ensure your prescriber documents the staging result explicitly.
2. Involve a specialist: The prescription must be by or in consultation with a gastroenterologist, endocrinologist, obesity medicine specialist, hepatologist, or liver transplant provider. A primary care physician prescribing without specialist consultation will need to document that consultation.
3. Confirm no cirrhosis: The criteria explicitly exclude cirrhosis. If your fibrosis has progressed to F4 (cirrhosis), the MASH carve-out does not apply.

If you have moderate-to-severe OSA and obesity (Zepbound OSA pathway)

1. Complete the 6-month CPAP trial first: The Zepbound OSA criteria require documented failure of a 6-month CPAP trial or a documented contraindication to PAP therapy. This is a step-therapy requirement; there is no exception pathway for CPAP-noncompliance alone.
2. Submit sleep study documentation: The criteria require submission of polysomnogram documentation showing AHI ≥ 15 events/hour at baseline. The sleep test device must be FDA-cleared as a diagnostic device.
3. Involve a sleep medicine specialist: Neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist prescribing/consultation is required.
4. Note the BMI requirement: BMI ≥ 30 (obesity) is required for Zepbound OSA, not merely overweight.

If you have T2DM

GLP-1 medications (Ozempic, Trulicity, Victoza, Mounjaro, and others) are covered for T2DM through the preferred-drug tier. No need to invoke the carve-out pathway. Call the Colorado Pharmacy Call Center at 888-672-7203 if your preferred T2DM agent is having PA issues.

If you want Wegovy or Zepbound for chronic weight management (no CVD, MASH, or OSA)

Health First Colorado does not cover GLP-1s for the chronic weight management indication. The PDL note is unambiguous: “Prior Authorization for GLP-1 analogues prescribed solely for weight loss will not be approved.” Saxenda, Qsymia, Contrave, phentermine, and Foundayo (orforglipron) are also not covered. If you are uninsured or have commercial coverage that denies GLP-1s for weight loss, see our appeal playbook for commercial insurance strategies and cash-pay alternatives.

Sources

Pattern #27 in the 50-state Medicaid GLP-1 series

Colorado is the 27th of 27 states fully documented in the 50-state Medicaid GLP-1 coverage series — the 27th of 27 distinct documented coverage patterns, representing 54% of the 50-state series. Pattern #27 is the dual-carve-out regulatory-exclusion state with permanent triple-indication positive coverage (Wegovy CV BMI ≥ 25 + Wegovy MASH + Zepbound OSA) + SB 25-048 large-group commercial mandate with express Medicaid/CHP+ carve-out + MedImpact PBM transition April 1, 2026 + DUR Board administered through University of Colorado Skaggs School of Pharmacy. Colorado joins a cluster of indication-anchored non-coverage states that have affirmatively added FDA-label carve-outs: Washington (Pattern #14), Oklahoma (Pattern #24), and Alabama (Pattern #23). Colorado is uniquely distinguished by the most permissive BMI threshold in the series (BMI ≥ 25 for Wegovy CV), the Wegovy oral tablet PDL entry (shared only with Washington), and the SB 25-048 split-track commercial mandate — the only enacted state commercial anti-obesity mandate in the 27-state series that expressly excludes the state's own Medicaid program.