Connecticut Medicaid HUSKY Health GLP-1 Coverage 2026: Pattern #30 — Partial-Reversal Triple-Carve-Out State (PA 23-171 Statutory Mandate Never Operationalized for GLP-1s + Serial Termination Jan 15 → June 14 → Aug 1, 2025 + Wegovy MACE + Zepbound OSA + Wegovy MASH with HUSKY B Exclusion) + SPA 25-0014 Phentermine/Orlistat-Only + FFS-Only Since 2012 + Gainwell/Prime/Acentra Triple-Vendor PBM Structure

Connecticut HUSKY Health — the state Medicaid program administered by the Connecticut Department of Social Services (DSS) for approximately 930,000–1,000,000 enrollees across four tracks (HUSKY A, B, C, D) — is Pattern #30 in the 50-state Medicaid GLP-1 series: the state with the largest statute-vs-operational-implementation gap in the 30-state series. Connecticut's legislature passed a clear statutory mandate in 2023 (Public Act 23-171) requiring HUSKY to cover FDA-approved weight-loss medications. The agency operationally delivered something entirely different: phentermine and orlistat only — representing roughly 5.5% of what a full GLP-1 implementation would cost.

The bottom line as of 2026-05-10: HUSKY Health does NOT cover GLP-1 receptor agonists for chronic weight management. The HUSKY Health Pharmacy member-facing page lists verbatim among non-covered categories: “Drugs to treat obesity.” Three FDA-label-restricted carve-outs are operationally active — Wegovy for MACE (effective February 3, 2025), Zepbound for OSA (effective July 1, 2025), and Wegovy for MASH (effective November 3, 2025) — but none covers chronic weight management. HUSKY B (CHIP) is uniquely excluded from the MASH carve-out.

The coverage termination followed a serial bulletin sequence: January 15, 2025 (new T2DM diagnosis code requirement), extended grace through June 14, 2025, then through July 31, 2025, with de facto claims termination August 1, 2025. Connecticut is FFS-only — it eliminated MCOs in 2012 — meaning a single statewide policy binds all HUSKY members simultaneously. Pharmacy runs through a unique triple-vendor structure: Gainwell Technologies (claims processor + PA reviewer), Prime Therapeutics (TOP$/PDL administration), and Acentra Health (RetroDUR). PA fax: 1-866-759-4110. PA phone: 1-866-409-8386.

1. The PA 23-171 Statutory Mandate That Never Delivered

In June 2023, Governor Lamont signed Public Act 23-171 (HB 6669, formerly Senate Bill 977), sponsored by Senator Matt Lesser. The statutory mandate required the Connecticut Medical Assistance Program (HUSKY Medicaid) to cover FDA-approved weight-loss medications for members with BMI > 40, or BMI > 35 with diagnosed comorbid conditions. The mandate also covered bariatric surgery and nutritional counseling for the same population.

The statute's mandate language, as paraphrased verbatim in the operationally-binding State Plan Amendment SPA 25-0014, is:

“the statute requiring Medicaid to cover FDA approved weight loss medications for those individuals with a Body Mass Index (BMI) greater than 40 or HUSKY Health members with a BMI greater than 35 with diagnosed comorbid conditions.”

The statute remains in force. PA 23-171 has not been repealed. What happened instead: from June 2023 through December 2024 — a period of 18 months — DSS did not operationalize GLP-1 weight-loss coverage at all, despite the statutory mandate. Members continued receiving GLP-1 prescriptions through the existing PDL T2DM pathway without a diagnosis-code restriction, but no obesity-class PA pathway was ever opened.

In December 2024, Sheldon Toubman of Disability Rights Connecticut sent a letter to Commissioner Andrea Barton Reeves documenting the non-implementation. The CT Mirror (December 23, 2024) quoted Toubman:

“Apparently, your agency knowingly disregarded the law for a year and half [sic].”

Rather than operationalizing full GLP-1 obesity coverage, DSS responded by issuing Provider Bulletin 2024-66 (December 6, 2024), which moved simultaneously to restrict existing GLP-1 coverage to T2DM only, and by proposing SPA 25-0014 in early 2025, which narrowly implemented the PA 23-171 mandate for orlistat and phentermine only.

The 5.5% Delivery Rate

SPA 25-0014's fiscal-impact statement is the clearest evidence of the gap. DSS estimated the amendment would increase aggregate expenditures by:

“approximately $504,008 in State Fiscal Year (SFY) 2025 and $4,157,990 in SFY 2026.”

Against the $85 million net-of-rebates GLP-1 spend in FY 2024 documented by the CT Mirror (March 23, 2025), the SPA 25-0014 phentermine/orlistat program represents approximately 5.5% of the prior GLP-1 expenditure. This is not a clinical replacement for GLP-1 class drugs — it is the minimum-cost statutory compliance gesture consistent with PA 23-171 remaining on the books while GLP-1 class coverage is operationally denied.

The statute says “FDA approved weight loss medications” (plural, generic class). The operational implementation covers two drugs representing a small fraction of the AOM market by clinical efficacy. This is the largest statute-vs-operational-implementation gap in the 30-state series.

2. The Serial Termination Timeline: January 15 → June 14 → July 31 / August 1, 2025

The operational termination of GLP-1 weight-loss coverage did not happen in a single bulletin. DSS issued a chain of three interlocking documents that together produced a final termination date of approximately August 1, 2025.

Step 1 — Provider Bulletin 2024-66 (December 6, 2024): The Diagnosis-Code Requirement

PB 2024-66 established that effective December 15, 2024, all new GLP-1 prescriptions would require a valid Type 2 diabetes ICD-10 code in NCPDP field 424-DO. Verbatim from the bulletin:

“Effective December 15, 2024, all new prescriptions for GLP-1 agonist medications will require a valid ICD-10 diagnosis code indicating Type 2 diabetes to be submitted in field 424-DO on the NCPDP D.0. pharmacy claim. These medications include Trulicity, Byetta, Bydureon, Rybelsus, Victoza/liraglutide, Ozempic, and Mounjaro (combination GIP and GLP-1).”

“Effective January 15, 2025, all GLP-1 medication pharmacy claims will require an approved Type 2 diabetes diagnosis code.”

Legacy members (those previously prescribed GLP-1s for non-T2DM indications) received a transition grace period. The original March 14, 2025 deadline was extended via a December 19, 2024 bulletin amendment to June 14, 2025.

Step 2 — Provider Bulletin 2025-31 (June 20, 2025): Final Extension to July 31, 2025

PB 2025-31 extended the grace period one final time, verbatim:

“The purpose of this Policy Transmittal is to inform pharmacies and providers that the Department of Social Services has extended the date for coverage for members who have been prescribed GLP-1 medications in the past for indications other than Type 2 diabetes. Claims will now continue to pay through July 31, 2025.”

The same bulletin simultaneously launched affirmative orlistat/phentermine coverage effective July 1, 2025. August 1, 2025 is the operational date on which non-T2DM GLP-1 claims stopped paying. Members who lost weight-loss coverage on that date received no further extension.

The Parallel Wegovy MACE Carve-Out: February 3, 2025

While the termination chain was in progress, DSS simultaneously added the first FDA-label carve-out via Provider Bulletin 2025-04 (January 17, 2025), effective February 3, 2025. Wegovy coverage was authorized exclusively for MACE risk reduction. The termination and the carve-out architecture were thus built in parallel — the agency was closing general coverage while opening indication-specific lanes.

3. The Three FDA-Label Carve-Outs Preserved

HUSKY Health has three active indication-anchored GLP-1 carve-outs as of 2026-05-10. Each requires prior authorization from Gainwell Technologies. PA forms are available at ctdssmap.com under the Pharmacy Information tab, Pharmacy Program Publications panel.

Carve-Out 1: Wegovy for MACE Risk Reduction (Effective February 3, 2025)

Verbatim from Provider Bulletin 2025-04:

“Effective February 3, 2025, the Department will reimburse for new prescriptions for Wegovy through the pharmacy benefit when prescribed to reduce the risk of Major Adverse Cardiac Event (MACE) in adults 18 and older with established cardiovascular disease and either obesity or overweight. This prescription will be reimbursed under the HUSKY Health Programs (A, B, C and D) for those meeting the specified criteria.”

Established cardiovascular disease means a documented history of one or more of:

“Established Cardiovascular disease includes presenting a medical history of 1 or more of the following: History of Myocardial Infarction; History of Ischemic or Hemorrhagic Stroke; History of Symptomatic Peripheral Arterial Disease.”

Explicit exclusions, verbatim:

“Wegovy will NOT be covered:
• Exclusively for weight management, or
• Type 1 or Type 2 diabetes, or
• For those who are also diagnosed with New York Heart Association Class IV Heart Failure.”

PA is required at each new therapy request and annually thereafter. Covered under HUSKY A, B, C, and D.

Carve-Out 2: Zepbound for Obstructive Sleep Apnea (Effective July 1, 2025)

Verbatim from Provider Bulletin 2025-32:

“Effective July 1, 2025, the Department will reimburse for new prescriptions for Zepbound through the pharmacy benefit when prescribed for the treatment of obstructive sleep apnea in adults 18 and older. This prescription will be reimbursed under the HUSKY Health Programs (A, B, C and D) for those meeting the following specified criteria.
• Established diagnosis of obstructive sleep apnea (OSA) which includes presenting with an apnea-hypopnea index (AHI) greater than or equal to 15”

“In addition, the member must also meet the following conditions:
• currently using AND will continue to use positive airway treatment (PAP) unless a contraindication to PAP exists
• active participation in comprehensive adjunct lifestyle interventions (e.g. diet modifications, physical activity, nutritional counseling, and/or behavioral therapy)
• diagnosis code G4733 (Obstructive sleep apnea) must be submitted on the pharmacy claim in Field 424-DO.”

Covered under HUSKY A, B, C, and D. PA required each new therapy and annually.

Carve-Out 3: Wegovy for MASH (Effective November 3, 2025) — HUSKY B Uniquely Excluded

Verbatim from Provider Bulletin 2025-54:

“Effective November 3, 2025, the Department will reimburse new prescriptions for Wegovy through the pharmacy benefit when prescribed to treat Metabolic-Associated Steatohepatitis (MASH) in adults 18 and older. This prescription will be reimbursed under the HUSKY Health Programs (A, C, and D) for those meeting the specified criteria.”

HUSKY B (Connecticut's CHIP program) is NOT covered for Wegovy MASH. This is the only carve-out in the three-carve-out architecture that explicitly excludes CHIP. PB 2025-54 covers “HUSKY Health Programs (A, C, and D)” — HUSKY B is omitted. This is unique in the 30-state series: no other Wegovy or Zepbound carve-out across any state explicitly excludes CHIP from the indication. HUSKY B serves children; MASH F2/F3 fibrosis is functionally adult-onset, which is the most plausible operational rationale, though the bulletin does not state one.

Established MASH criteria, verbatim:

“Established Metabolic-Associated Steatohepatitis (MASH) includes presenting a medical history of the following:
• histologically documented steatohepatitis
• NAFLD Activity Score (NAS) greater than or equal to 4
• A hepatic decompensation or Model for End-Stage Liver Disease (MELD) score of less than or equal to 12 points
• AST and ALT levels are less than or equal to 5 times upper limit of normal.”

“Wegovy will NOT be covered:
• Exclusively for weight management, or
• Type 1 or Type 2 diabetes”

PB 2025-54 also established a hard diagnosis-code requirement on all Wegovy prescriptions:

“Effective November 3, 2025, all Wegovy prescriptions will require a diagnosis code. Only diagnosis codes that indicate an established major adverse cardiovascular event or for established MASH will be payable.”

4. SPA 25-0014: Phentermine and Orlistat — The Statutory Compliance Minimum

The only two anti-obesity medications covered through the HUSKY pharmacy benefit for chronic weight management as of 2026-05-10 are orlistat (generic and Xenical brand) and phentermine, added via SPA 25-0014 effective July 1, 2025. Verbatim from the State Plan Amendment notice:

“Effective on or after June 1, 2025, or upon CMS approval, whichever is later, SPA 25-0014 will amend Attachment 4.19-B in order to provide limited coverage of the Food and Drug Administration (FDA) approved weight loss medications to include orlistat, Xenical, and phentermine.”

“The purpose of this SPA is to address the statute requiring Medicaid to cover FDA approved weight loss medications for those individuals with a Body Mass Index (BMI) greater than 40 or HUSKY Health members with a BMI greater than 35 with diagnosed comorbid conditions.”

The State Plan attachment adds the payment methodology verbatim:

“Weight loss medications — Claims for orlistat, Xenical, and phentermine will be payable based on 1 above and will receive a professional dispensing fee of $10.75.”

Eligibility mirrors the PA 23-171 BMI thresholds: HUSKY A, B, C, D members with BMI > 40, or BMI > 35 with diagnosed comorbid conditions. No GLP-1 class drug is enumerated in SPA 25-0014. The omission is itself the operational evidence that DSS used the SPA to narrowly implement PA 23-171 without including the GLP-1 class.

Note on phentermine: phentermine is a DEA Schedule IV controlled substance. PB 2025-31 and the SPA 25-0014 notice do not impose explicit day-supply limits or single-prescriber requirements in their published text. Members and prescribers should verify current operational criteria with Gainwell (1-866-409-8386).

5. FFS-Only Architecture Since 2012: Why Connecticut Is Structurally Different

Connecticut is the only state in the 30-state series with no capitated managed care organizations (MCOs) in its Medicaid program. This structural fact is the most important context for understanding why the Lamont administration's fiscal concern about GLP-1 spending cascaded directly into a coverage termination.

The 2011–2012 MCO Elimination

From the early 2000s through 2011, HUSKY operated through capitated MCOs: Aetna Better Health of Connecticut, UnitedHealthcare AmeriChoice of Connecticut, and Community Health Network of Connecticut (CHNCT). In late 2011, DSS terminated approximately $800 million in capitated MCO contracts after extended controversy over MCO administrative costs, denied claims, and access-to-care failures. Connecticut converted entirely to a fee-for-service model with non-risk-bearing Administrative Services Organizations (ASOs).

The replacement architecture — still operative today — is:

• Medical ASO: Community Health Network of Connecticut, Inc. (CHNCT) — converted from capitated MCO to non-risk-bearing ASO; provides care coordination and case management.
• Behavioral Health ASO: Carelon Behavioral Health (formerly Beacon Health Options, formerly ValueOptions) — operates the Connecticut Behavioral Health Partnership (CTBHP).
• Dental ASO: BeneCare Dental Plans, Inc.
• Pharmacy benefit: Direct DSS administration through three vendors (Gainwell, Prime Therapeutics, Acentra Health).

None of these entities bears capitated risk. DSS itself is the payer of last resort.

Why FFS-Only Makes GLP-1 Fiscal Pressure More Direct

In a capitated MCO state (Georgia, Florida, Texas, North Carolina), an $85 million GLP-1 spend would be substantially absorbed by MCO capitation payments already paid to the MCO. The MCO bears the risk. When the MCO takes a loss on GLP-1s, it negotiates rebate arrangements, adjusts its own formulary, or accepts reduced margin — but the state's direct fiscal exposure is the capitation rate, not the drug spend.

In Connecticut's FFS-only architecture, the $85 million FY 2024 GLP-1 spend is direct state-budget exposure. Every Wegovy or Saxenda prescription paid by HUSKY is a direct draw on the state pharmacy appropriation. The CT Mirror (March 23, 2025) documented that GLP-1 medications represented approximately 35% of the entire HUSKY Medicaid pharmaceutical budget for FY 2024. Against a projected $290 million Medicaid pharmacy deficit, the Lamont administration estimated $45.6 million in two-year savings from terminating GLP-1 weight-loss coverage.

This is the structural reason the fiscal pressure became a coverage termination. The same economic dynamic would not have produced the same outcome in a capitated-MCO state, because the state would have had a fiscal buffer.

Practical Implications for Members

FFS-only architecture has two practical implications HUSKY members should understand:

• No MCO to call. There are no HUSKY managed care organizations. Members who search for “HUSKY MCO” or attempt to call an MCO member services line will not reach the correct entity. All HUSKY pharmacy questions go to the HUSKY Health Pharmacy Customer Call Center at 1-866-409-8430 (member-facing, Monday–Friday 8 a.m.–5 p.m.) or the Gainwell Pharmacy Prior Authorization Assistance Center at 1-866-409-8386 (provider-facing).
• Single statewide policy. One DSS policy decision (one bulletin) binds all HUSKY A/B/C/D members simultaneously. There is no MCO-by-MCO variation. The criteria in PB 2025-04 apply identically to a Hartford HUSKY D member and a Stamford HUSKY B child.

6. The Triple-Vendor PBM Structure: The Most Complex in the 30-State Series

No other state in the 30-state series has a pharmacy architecture with three operationally-distinct vendor relationships performing different pharmacy-benefit functions. Connecticut's triple-vendor FFS pharmacy structure is unique in the series.

Gainwell Technologies — Claims Processor + PA Reviewer

Gainwell Technologies is the CMAP fiscal agent and pharmacy claims processor. Gainwell adjudicates every pharmacy PA decision and prepares the Clinical PA Criteria documents (e.g., the Hypoglycemics, Incretin Mimetics/Enhancers PA Criteria V3, dated 4/29/2026, copyright “© 2026 Gainwell Technologies. All rights reserved.”). The PA submission instructions in PB 2025-59 state verbatim:

“Prior authorizations must be submitted via fax similar to the existing process used today. The completed prior authorization form must be prepared and signed by the prescribing provider and faxed to 1-866-759-4110.”

Complete Gainwell contact information:

• Pharmacy PA phone: 1-866-409-8386 (Pharmacy Prior Authorization Assistance Center)
• PA fax: 1-866-759-4110
• TTY/TDD: 1-866-604-3470
• Mailing address: Gainwell Technologies, PO Box 2991, Hartford, CT 06104
• PDL Coordinator: 1-571-348-0187 / ConnecticutPDLQuestions@gainwelltechnologies.com
• Provider Assistance Center: 1-800-842-8440 (Monday–Friday 8 a.m.–5 p.m.)
• Letter of Medical Necessity email (DSS CMO): rx.lmn@ct.gov

Prime Therapeutics — TOP$/PDL Administration

Prime Therapeutics administers the TOP$ (Therapeutic Options Program) — the operational engine of PDL adoption, review, and supplemental rebate negotiation. Prime is also the administrator for the Connecticut AIDS Drug Assistance Program (CADAP) and the Connecticut Insurance Premium Assistance (CIPA) program. Prime is not the claims processor for HUSKY — Gainwell is. Prime operates the PDL program logic and drug-class evaluation. The CADAP/CIPA contact is CTMyRxEnroll@primetherapeutics.com / ctdph.primetherapeutics.com.

Acentra Health — RetroDUR

Acentra Health administers the Retrospective Drug Utilization Review (RetroDUR) Program, analyzing claims data against DUR-Board-approved criteria to identify aberrant prescribing, client misuse, and provider fraud. Acentra also administers pharmacy restriction initiatives (single-pharmacy lock-in for members demonstrating drug misuse). Acentra is not the PA reviewer or claims processor — Gainwell handles both. Contact: 1-877-719-3123 / fax 1-866-743-9788.

Carelon Behavioral Health — BH Pharmacy Carve-Outs

Carelon (operating as CTBHP) separately administers behavioral-health pharmacy PA criteria including Spravato (esketamine) coverage guidelines. GLP-1 prescriptions are never routed through Carelon — they go through Gainwell. Members familiar with the CTBHP pathway for mental health medications should use the Gainwell contact above for any GLP-1 PA.

The P&T Committee governing PDL decisions is established under Conn. Gen. Stat. § 17b-274d. The PDL is formally adopted by the DSS Commissioner following P&T Committee recommendation. There is currently no “Anti-Obesity Medications” or “Weight Management Agents” PDL class in HUSKY — the statute mandating coverage (PA 23-171) exists without a corresponding PDL class to deliver it for GLP-1s.

7. HB 7192 (2025): The Generic GLP-1 Production Directive

In 2025, Governor Lamont signed HB 7192 (a prescription drug omnibus bill). The provision most relevant to GLP-1 access directs DSS to “partner with the federal government to seek the generic production of GLP-1 weight loss drugs.”

This is a distinct second policy track from the PA 23-171 mandate. HB 7192 does NOT mandate HUSKY Medicaid coverage of GLP-1 obesity drugs — it directs a federal partnership for production-cost reduction. Senator Lesser is HB 7192's chief proponent. HB 7192 also includes PBM-reform provisions that update the PBM practices study framework established under PA 23-171 Section 7 (directed the Office of Health Strategy to study and report on commercial PBM practices in Connecticut).

The strategic logic is: if the barrier to operationalizing the PA 23-171 mandate is cost (“the cost was overwhelming due to high demand and drug company profiteering” — Senator Lesser, May 2026), then the path to restoring coverage is reducing the drug price through generic production or federal negotiation, not modifying the statutory mandate that already exists.

Note: The exact act number for HB 7192 (Public Act 25-___) was referenced in the brief as unconfirmed from cga.ct.gov; the bill's signing and GLP-1 production directive provision are sourced from verified Senator Lesser press release language and verifier brief documentation.

8. AG Tong's Compounded-GLP-1 Enforcement: A Parallel Track

Connecticut Attorney General William Tong has pursued a parallel enforcement track targeting compounded and counterfeit GLP-1 products. In June 2025, the AG sued Triggered Brand — a compounded-GLP-1 distributor — for consumer-protection violations. In 2026, the AG announced an Online Platform Initiative to halt bootleg weight-loss drug sales on consumer-facing digital platforms.

These enforcement actions are not HUSKY pharmacy benefit policies. The AG's consumer-protection mandate is the prevention of fraud and harm from non-FDA-approved compounded products — a separate legal track from DSS's pharmacy benefit decisions. A HUSKY member denied GLP-1 coverage for obesity cannot obtain a remedy through the AG's office; appeals go to DSS OLCRAH (see Section 10 below). The AG enforcement context is relevant background for understanding Connecticut's overall GLP-1 policy environment, but it does not affect HUSKY coverage rules.

9. CMS BALANCE Model: The Federal Pathway Forward (Launching May 2026)

The federal Centers for Medicare & Medicaid Services announced the BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth), a voluntary pilot allowing Medicaid and Medicare programs to cover GLP-1 weight-loss drugs at reduced cost through a federal pricing arrangement. State Medicaid programs and manufacturers were asked to submit intentions to participate by January 8, 2026, with model launch expected May 2026.

Senator Lesser's May 6, 2026 press release stated:

“Two years ago, I wrote a law requiring Connecticut's Medicaid program to cover GLP-1 drugs, but the cost was overwhelming due to high demand and drug company profiteering.”

The press release stated Connecticut “should seriously consider participating” in the BALANCE Model. As of 2026-05-10, DSS has not published a formal announcement confirming CT's BALANCE Model participation status. If Connecticut joins the BALANCE Model, this could be the mechanism through which the PA 23-171 mandate is finally operationalized for the GLP-1 class — if the federal pricing arrangement brings net costs within the state's budget tolerance.

10. Senator Matt Lesser: Architect AND Unwinder of the GLP-1 Mandate

Senator Matt Lesser's role in Connecticut's GLP-1 coverage saga is unique in the 30-state series: he is both the architect of the 2023 mandate (PA 23-171) and the most prominent public voice for the 2025 successor strategy that effectively acknowledged the mandate's operational failure.

Lesser sponsored Senate Bill 977 in 2023, which became the HB 6669 that Governor Lamont signed as PA 23-171. The statute was designed to guarantee HUSKY members access to FDA-approved weight-loss medications at the BMI thresholds above.

Two years later, with the mandate operationalized for only orlistat and phentermine, and with GLP-1 weight-loss coverage terminated by the Lamont administration's budget, Senator Lesser's public statement is the most candid acknowledgment by any state legislator in the 30-state series:

“Two years ago, I wrote a law requiring Connecticut's Medicaid program to cover GLP-1 drugs, but the cost was overwhelming due to high demand and drug company profiteering.”

Lesser's 2025 pivot was to sponsor HB 7192 — the generic GLP-1 production directive that takes a supply-side approach to cost. Rather than repealing the statutory mandate or accepting the orlistat/ phentermine implementation as the endpoint, Lesser is now advocating for federal cost-reduction mechanisms (BALANCE Model participation) as the path to actually delivering what PA 23-171 promised.

The political arc — write the mandate, watch the mandate get operationally sidelined by fiscal pressure, advocate for a federal cost-reduction mechanism to make the mandate deliverable — is the defining story of Pattern #30. No other state legislator in the 30-state series occupies this position of having authored both the mandate and its successor cost-control strategy.

11. T2DM GLP-1 Coverage: Intact Under the Hypoglycemics PA Criteria V3

While GLP-1 coverage for chronic weight management is terminated, HUSKY Health continues to cover GLP-1 receptor agonists for type 2 diabetes mellitus (T2DM) through the Hypoglycemics, Incretin Mimetics/Enhancers PDL class. The binding clinical criteria are V3 (April 29, 2026), effective January 1, 2026 (after a 90-day transitional period ending March 31, 2026).

Preferred agents (no PA required): Byetta (exenatide), Ozempic (semaglutide) injection, Trulicity (dulaglutide), Victoza (liraglutide).

Non-preferred agents (PA required): Bydureon BCise (Exenatide ER), Exenatide, Liraglutide (generic Victoza), Mounjaro (tirzepatide), Ozempic (semaglutide) tablets, Rybelsus (semaglutide), Soliqua (insulin glargine + lixisenatide), Xultophy (insulin degludec + liraglutide).

Verbatim initial-therapy criteria for non-preferred GLP-1 agents:

“Initial Therapy – All the following must be met:
• Documented diagnosis of type 2 diabetes mellitus as defined by one or more of the following (must be documented in a chart note or with laboratory results):
  • A1c ≥6.5% (≥48 mmol/mol)
  • Fasting plasma glucose ≥126 mg/dL (≥7.0 mmol/L)
  • 2 hour plasma glucose ≥200 mg/dL (≥11.1 mmol/L) during oral glucose tolerance test
  • Classic symptoms of hyperglycemia or hyperglycemic crisis and a random plasma glucose ≥200 mg/dL (≥11.1 mmol/L) AND
• Trial and failure of a preferred agent (Byetta, Ozempic injection, Trulicity, Victoza) as defined by failure to improve or maintain improvement in glycemic control ... OR documented adverse drug reaction/adverse drug event or contraindication”

Key operational notes: Gastrointestinal side effects are not considered an intolerance (expected class effects) unless the prescriber provides medical justification for discontinuation. Continuation requires documented compliance, T2DM diagnosis, and recent (within 180 days) laboratory values demonstrating glycemic improvement or maintenance — CT does not auto-renew without recent A1c documentation.

Important warning for HUSKY members on Mounjaro, Ozempic tablets, Rybelsus, or other non-preferred GLP-1s for T2DM: the previously-approved PDL PAs for these drugs in the Hypoglycemics class were invalidated effective April 1, 2026 (per PB 2025-59). If you have not yet submitted a new clinical PA under the V3 criteria, your coverage may have lapsed. Fax a new PA form to 1-866-759-4110 as soon as possible.

12. Appeals: HUSKY Fair Hearings via DSS OLCRAH

Because HUSKY Health has no MCOs, the appeals pathway skips the MCO internal-appeal layer that exists in most other states. A denied pharmacy PA proceeds directly to the DSS Office of Legal Counsel, Regulations and Administrative Hearings (OLCRAH) at 55 Farmington Avenue, Hartford, CT 06105.

Verbatim from the OLCRAH Hearing Request page:

“the hearing request must be made within 60 days from the date of the DSS Notice of Action”

“For Medicaid (HUSKY), benefits may continue if the hearing request is made any time before the date of the proposed action”

“The Hearing Officer will issue the final decision not later than 90 days after the date DSS receives the hearing request.”

Reconsideration is available within 15 days of the decision on three grounds:

“(1) there is an error of fact or law that needs to be corrected; (2) new evidence was discovered that could not have been presented at the hearing; or (3) other good cause for reconsideration is shown.”

After OLCRAH, judicial review is available through the Connecticut Superior Court under Conn. Gen. Stat. § 4-183 (Uniform Administrative Procedure Act). Members may seek free legal assistance through Statewide Legal Services at 1-800-453-3320 or 860-453-3320.

Practical notes for a HUSKY GLP-1 PA denial appeal:

• The 60-day clock starts from the Notice of Action date on the denial letter, not the date you received it.
• For HUSKY Medicaid (A/C/D), request continued benefits by filing before the proposed action date (more lenient than the 10-day standard for other DSS programs).
• A fair hearing cannot override the categorical exclusion for chronic weight management — if you do not meet the MACE, MASH, or OSA criteria, the exclusion stands. The strongest appeal posture is when PA criteria were met but the documentation was incomplete or miscoded.
• The Letter of Medical Necessity (LMN) pathway is available for consideration by the DSS Chief Medical Officer at rx.lmn@ct.gov (per PB 2025-59).

13. How Connecticut Compares: WA, NJ, PA, OK, and MD Analogues

Connecticut's Pattern #30 is structurally distinctive in the 30-state series. Here is how it compares to the five closest analogues:

• Washington Apple Health (Pattern #14) — the closest operational analogue. WA has the same triple FDA-label carve-out architecture (Wegovy MACE + Wegovy MASH + Zepbound OSA) over a categorical exclusion. Key differences: WA has five MCOs (CT has none); WA lacks the PA 23-171 statutory mandate and the SPA 25-0014 phentermine/orlistat pharmacy benefit; WA's categorical exclusion is codified in WAC 182-530-2100(1)(b)(i), while CT's is at the member-facing page level plus bulletin chain. CT is Pattern #30 — the FFS-only, statute-gap version of WA's architecture.
• New Jersey Medicaid (Pattern #11) — the closest legislative-trajectory analogue. NJ has active reversal-direction legislation (A3369) that would mandate Medicaid GLP-1 coverage — but it has not passed. CT's mandate (PA 23-171) was passed in 2023 and narrowly implemented. CT's trajectory (mandate passed → operational non-implementation → SPA minimum-compliance) is the scenario NJ stakeholders should model if A3369 eventually passes.
• Pennsylvania Medicaid (Pattern #7) — the closest termination analogue. PA terminated chronic-weight-management coverage effective January 1, 2026 via MAB2025112403. CT's termination predated PA's by approximately six months (CT: August 1, 2025; PA: January 1, 2026). PA's termination was more total — no phentermine/orlistat pharmacy-benefit replacement was added.
• Oklahoma SoonerCare (Pattern #24) — the closest triple-carve-out analogue. OK has Wegovy CV + Wegovy MASH + Zepbound OSA + Imcivree-monogenic carve-outs over OAC 317:30-5-72.1(1)(D). CT has the same three core carve-outs but no Imcivree pathway. CT adds the SPA 25-0014 phentermine/orlistat pharmacy benefit which OK does not have.
• Maryland Medicaid (Pattern #17) — the closest contrast. MD operationally covers Wegovy and similar drugs for chronic weight management through the MMPP PDL “Anti-Obesity Drugs” class. CT has the statutory authority to do the same (PA 23-171) but has not operationalized it. MD illustrates that statutory authority is necessary but not sufficient — operational implementation requires sustained fiscal commitment. For New England readers: if you live in Massachusetts (Pattern #15), your Medicaid-equivalent covers Wegovy for chronic weight management; if you live in Connecticut, it does not.

14. What HUSKY Patients Can Do in 2026

If you are a HUSKY Health member who lost GLP-1 coverage as of August 1, 2025, or who has been denied GLP-1 coverage for obesity, here are your options:

1. Establish a qualifying FDA-label indication. If you have documented cardiovascular disease (prior MI, stroke, or symptomatic PAD) AND are obese or overweight — Wegovy MACE pathway may apply (PB 2025-04, PA fax 1-866-759-4110). If you have moderate-to-severe OSA with AHI ≥ 15 and are using PAP therapy — Zepbound OSA pathway may apply (PB 2025-32, same PA fax). If you have histologically documented MASH with NAS ≥ 4 and MELD ≤ 12 — Wegovy MASH pathway may apply for HUSKY A/C/D members (PB 2025-54; HUSKY B is excluded).
2. Access phentermine or orlistat through SPA 25-0014. If you have BMI > 40 (or BMI > 35 with diagnosed comorbidities), these two oral weight-loss drugs are covered through the HUSKY pharmacy benefit effective July 1, 2025. They are not GLP-1 class drugs, but they are covered at $0 copay for HUSKY A/C/D. Contact your prescriber or call 1-866-409-8386.
3. Establish T2DM if clinically appropriate. GLP-1 class drugs (including Mounjaro and Ozempic) are covered for type 2 diabetes. If you have an A1c ≥ 6.5% or equivalent diagnostic criteria, a T2DM diagnosis unlocks the Hypoglycemics PDL pathway. This is a clinical pathway, not an access workaround — only pursue it if you genuinely have T2DM.
4. Submit a Letter of Medical Necessity. PB 2025-59 explicitly allows prescribers to submit an LMN to the DSS Chief Medical Officer at rx.lmn@ct.gov. This is an alternative path for clinically compelling cases outside the standard PA criteria.
5. Appeal a PA denial to DSS OLCRAH within 60 days. If your PA was denied and you believe the criteria were met but improperly applied, file a fair hearing request with DSS OLCRAH at 55 Farmington Avenue, Hartford, CT 06105 within 60 days of the Notice of Action. Decision within 90 days. Free legal help: Statewide Legal Services 1-800-453-3320. See also our GLP-1 insurance dropped coverage appeal playbook for documentation strategy.
6. Contact Senator Lesser's office. The 2023 mandate (PA 23-171) is still on the books. The political coalition that passed it is still in the legislature. If you believe CT's narrow SPA 25-0014 implementation does not fulfill the statutory mandate, Senator Lesser's office and the Health Committee are the appropriate venues to weigh in on the BALANCE Model participation decision and the future of GLP-1 obesity coverage in Connecticut.

15. Series Context: Where CT Fits in the 50-State Medicaid GLP-1 Series

For broader 50-state Medicaid GLP-1 coverage context, see our GLP-1 insurance coverage: Medicare, Medicaid, and commercial hub article. The taxonomy now covers 30 articles + 30 distinct documented coverage patterns — 60% of the 50-state series. Connecticut is Pattern #30 — the FFS-only HUSKY state with a 2023 statutory obesity-medication-coverage mandate (PA 23-171) that was operationally narrowed by the Lamont administration's FY 2025–26 budget into a three-track FDA-label-restricted carve-out (Wegovy MACE + Zepbound OSA + Wegovy MASH) plus a two-drug oral AOM pharmacy benefit (orlistat + phentermine) — Gainwell-claims / Prime-PDL / Acentra-RetroDUR triple-vendor pharmacy infrastructure — directly-adjudicated DSS OLCRAH appeals.

For GLP-1 side effects and tolerability guidance relevant to members who are approved under the MACE, MASH, or OSA carve-outs, see our GLP-1 side effect questions answered hub.