Kansas Medicaid GLP-1 Coverage 2026: Pattern #43 — Positive-Coverage Non-Expansion State That LOOSENED AOM Criteria Mid-Retrenchment (Wegovy + Zepbound De-Listed from High-Cost Table 4 in 2024-2025) Under KanCare 3.0 With Sunflower / UnitedHealthcare / Healthy Blue MCOs

TL;DR — what Kansas Medicaid covers and how it changed in 2024-2025

Kansas Medicaid covers Wegovy and Zepbound for chronic weight management under the Anti-Obesity Medications PA pathway. Saxenda is covered as non-preferred (PA required). The single most consequential 2024-2025 policy change is the de-listing of Wegovy and Zepbound from Table 4 of the KDHE AOM clinical criteria.

The Pattern #43 anchor quote from the KDHE Anti-Obesity Medications PA Form (Rev. 06/2025), Section III question 9, verbatim:

“Note: Zepbound (as of 4/1/24) and Wegovy (as of 6/1/25) are currently NOT LISTED in Table 4.”

Table 4 historically housed the “high-cost-agent” AOMs at a BMI ≥ 40 (severe obesity) gate. By removing Wegovy and Zepbound from Table 4, KDHE moved both drugs to the general AOM criteria pathway: adult BMI ≥ 30 OR BMI ≥ 27 with a Table 2 weight-related comorbidity. Saxenda (liraglutide) IS still in Table 4 and still requires BMI ≥ 40.

What KS Medicaid covers in the Anti-Obesity Medications class (per KS Medicaid PDL Last Updated 05/01/2026, page 12):

• Preferred: Wegovy injection AND tablets (semaglutide); Wegovy HD (semaglutide); Zepbound (tirzepatide)
• Non-preferred, PA required: Saxenda (liraglutide)

What KS Medicaid covers in the GLP-1 Receptor Agonists class for T2D (PDL page 20):

• Preferred: Ozempic (semaglutide); Trulicity (dulaglutide); Victoza (liraglutide)
• Non-preferred, PA required: Adlyxin; Bydureon BCise; Byetta; Rybelsus (semaglutide)
• Notable: Mounjaro (tirzepatide for T2D) is NOT listed on the GLP-1 RA PDL section — covered via Diabetes Mellitus Type 2 Agents PA pathway (revised 04/16/2025), Table 1 of which lists tirzepatide for adults ≥ 18 years with 15 mg SQ weekly maximum dose.

Pattern #43 distinctive features vs. the prior 42 states in the series:

• Wegovy + Zepbound de-listed from “high-cost agent” Table 4 in 2024-2025 — the major access expansion. PA Form note: “Zepbound (as of 4/1/24) and Wegovy (as of 6/1/25) are currently NOT LISTED in Table 4.” This eliminated the BMI ≥ 40 severe-obesity gate for both drugs and moved them to the general AOM criteria pathway (BMI ≥ 30, or BMI ≥ 27 with Table 2 comorbidity). Inverse trajectory of RI Pattern #40 (active-coverage state with FY27 sunset proposal): Kansas LOOSENED during a period of national retrenchment.
• KanCare 3.0 MCO turnover — effective January 1, 2025: Aetna OUT (contract ended 12/31/2024), Healthy Blue IN (BCBS of Kansas + Elevance/Anthem joint venture). Members on Aetna with active PA approvals had to re-establish under one of three new MCOs (Sunflower, UHC, Healthy Blue).
• Non-Medicaid-expansion state — 1 of only 10 remaining. Concentrates AOM/GLP-1 access on Medicaid-eligible parents, pregnant women, children, disabled adults, seniors. HAWK Act HB 2375 (2025-2026) expansion bills died in committee.
• Pediatric AOM coverage including Wegovy ≥ 12 via Table 3 CDC 95th-percentile BMI cutoffs. Saxenda and Wegovy both have FDA pediatric labeling and KDHE coverage ≥ 12; Zepbound restricted to ≥ 18 (matches FDA label).
• Statewide GLP-1 access reduction at the state-employee level — NOT KanCare. Kansas SEHP raised BMI threshold for GLP-1 coverage for weight management to BMI ≥ 35 effective January 1, 2026 (Caremark-administered, not KanCare). KanCare retained the more lenient BMI ≥ 30 / ≥ 27 + comorbidity standard. Kansas Medicaid is MORE generous on AOM access than Kansas’s own state-employee plan.
• FFS pharmacy paper-claim discontinuation effective January 1, 2026 per KMAP Bulletin 25305 — all FFS pharmacy claims now electronic via Gainwell-administered MMIS. Minor operational impact.

PA submission architecture:

• KMAP FFS: PA phone 1-800-933-6593; PA fax 1-800-913-2229
• Healthy Blue of Kansas: PA phone 1-833-838-2595 (pharmacy + medical); PA fax 1-877-941-9901 (pharmacy) / 1-877-941-9841 (medical)
• Sunflower Health Plan: PA phone 1-877-397-9526 (pharmacy) / 1-877-644-4623 (medical); PA fax 1-833-645-2740 (pharmacy) / 1-888-453-4756 (medical)
• UnitedHealthcare Community Plan of Kansas: PA phone 1-800-310-6826 (pharmacy) / 1-866-604-3267 (medical); PA fax 1-866-940-7328 (pharmacy)
• PA Form: KDHE Anti-Obesity Medications Prior Authorization Form (Rev. 06/2025). Drug menu Section I: Liraglutide (Saxenda); Semaglutide (Wegovy); Tirzepatide (Zepbound).
• Adjudication: Federal 42 CFR 438.210 standard = 14 calendar days standard, 72 hours expedited. KS-specific SLA in days: UNVERIFIED.

1. Federal authority: 42 U.S.C. § 1396r-8(d)(2)(A)

The federal Medicaid drug rebate statute at 42 U.S.C. § 1396r-8(d)(2)(A) grants states an optional authority to exclude “Agents when used for anorexia, weight loss, or weight gain” from coverage. Kansas has NOT exercised this exclusion authority. Instead, Kansas Medicaid has covered AOMs under a unified clinical criteria framework administered by KDHE since the original Anti-Obesity Agents clinical criteria document was issued on September 14, 2007 (most recent revision January 17, 2024).

Kansas is therefore a positive-coverage state on AOMs — in the same KFF January 2026 13-state cohort as Massachusetts, Connecticut, New York, Michigan, Wisconsin, Mississippi, Rhode Island, Delaware, and approximately four others. Within that cohort, Kansas is unusual because: (1) it is a non-expansion state, (2) it covers Wegovy + Zepbound at adult BMI ≥ 30 (no severe-obesity gate after the 2024-2025 Table 4 de-listing), and (3) it has measurably LOOSENED criteria during a period when peer state Medicaid programs (CA, NH, PA, SC) were dropping coverage.

The Wegovy CVD pathway operates under the same AOM PA Form — not via a separate State Plan Amendment or carve-back-in — with the explicit verbatim language at Section III question 9A: “For Wegovy only: Adults with BMI ≥ 27 kg/m² AND has established cardiovascular disease (CVD) and NOT have a history of type 1 nor type II diabetes.”

2. PDL anchor: Kansas Medicaid Preferred Drug List (Last Updated May 1, 2026)

The Kansas Medicaid Preferred Drug List last updated May 1, 2026 is the binding formulary document for KanCare pharmacy coverage. Two AOM-relevant sections appear on the PDL.

2.1 Anti-Obesity Medications class (PDL page 12)

Verbatim from PDL page 12:

Preferred: “Wegovy® Injection and Tablets (semaglutide)”; “Wegovy® HD (semaglutide)”; “Zepbound® (tirzepatide)”

Non-preferred, PA required: “Saxenda® (liraglutide)”

All four AOM agents in the class are GLP-1- or GIP-GLP-1-based. The KDHE preferred-tier choice prioritizes the two highest-list-price brand-name agents (Wegovy and Zepbound) ahead of Saxenda — reflecting the post-Table-4-de-listing access posture combined with Medicaid rebate negotiations.

2.2 GLP-1 Receptor Agonists class (PDL page 20)

Verbatim from PDL page 20:

Preferred: Ozempic® (semaglutide); Trulicity® (dulaglutide); Victoza® (liraglutide)

Non-preferred, PA required: Adlyxin®; Bydureon® BCise™; Byetta®; Rybelsus® (semaglutide)

Notable: Mounjaro (tirzepatide for T2D) is NOT listed in the PDL GLP-1 Receptor Agonists class. Mounjaro is covered via the separate Diabetes Mellitus Type 2 Agents PA pathway (revised April 16, 2025), Table 1 of which lists tirzepatide for adults ≥ 18 with a 15 mg subcutaneous weekly maximum dose.

The Ozempic-preferred posture in Kansas contrasts with Vermont Pattern #41 (Ozempic non-preferred / Mounjaro preferred) and reflects the more common Medicaid PDL placement nationally. Patients established on Ozempic transitioning into KanCare from commercial insurance typically face no preferred-tier obstacle.

3. Anti-Obesity Medications clinical criteria

The KDHE Anti-Obesity Agents clinical criteria document (initially issued September 14, 2007; most recent revision January 17, 2024) is the binding clinical criteria document referenced by the AOM PA Form. The criteria operate across three eligibility groups: adults general, adolescents 12-17, and Wegovy CVD (which has its own pathway at BMI ≥ 27 + established CVD).

3.1 Adult eligibility (general AOM)

Adults qualify for Wegovy or Zepbound under the general AOM criteria if they meet either of two BMI thresholds:

• BMI ≥ 30 kg/m² (obesity), OR
• BMI ≥ 27 kg/m² with at least one Table 2 weight-related comorbidity

Table 2 weight-related comorbidities (the qualifying list):

• Type 2 diabetes mellitus (T2DM)
• Prediabetes
• Hypertension (HTN)
• Dyslipidemia
• Cardiovascular disease (CVD)
• Nonalcoholic fatty liver disease / Nonalcoholic steatohepatitis (NAFLD / NASH)
• Polycystic ovary syndrome (PCOS)
• Obstructive sleep apnea (OSA)
• Gastroesophageal reflux disease (GERD)
• Depression
• Infertility
• Cancer
• Osteoarthritis (OA)
• Asthma
• Urinary stress incontinence
• Male hypogonadism

The Table 2 list is unusually broad relative to peer state AOM criteria. For example, GERD, depression, infertility, OA, asthma, urinary stress incontinence, and male hypogonadism are all qualifying weight-related comorbidities in Kansas Medicaid AOM criteria but are NOT recognized in many peer state Medicaid AOM criteria. This breadth means a Kansas Medicaid beneficiary at BMI 28 with mild GERD or depression qualifies for Wegovy or Zepbound under the standard pathway — the BMI ≥ 27 + comorbidity bar is genuinely accessible rather than narrowly cardiometabolic.

3.2 Adolescent eligibility (ages 12-17)

Adolescents ages 12 through 17 qualify for Wegovy or Saxenda (Zepbound is restricted to ≥ 18, matching FDA label) if their BMI is at or above the 95th percentile for age and sex per Table 3, which lists explicit BMI cutoffs derived from CDC growth charts. PA Form Section III question 6 verbatim:

“If the medication requested is for a pediatric patient (≥ 12 and < 18 years of age), does the patient have a BMI (standardized for age and sex) in the 95th percentile or greater as listed in Table 3 on the corresponding criteria?”

Selected Table 3 cutoffs (illustrative):

The Table 3 CDC-growth-chart approach in the PA form is structurally similar to Mississippi Pattern #35 (which also operationalizes pediatric AOM via CDC growth-chart percentile cutoffs). Kansas families with adolescent KanCare beneficiaries seeking Wegovy should ensure: (1) the patient’s BMI is calculated to one decimal place using the standard formula (weight in kg / height in m²) rather than estimated; (2) the height-and-weight measurement is recent (within 6 months); (3) the prescribing pediatrician or adolescent medicine specialist references Table 3 in the PA submission narrative; (4) the prescription is consistent with the FDA STEP TEENS labeling.

3.3 Wegovy CVD pathway (BMI ≥ 27 + established CVD)

For Wegovy specifically, an additional eligibility pathway operates at lower BMI thresholds. PA Form Section III question 9A verbatim:

“For Wegovy only: Adults with BMI ≥ 27 kg/m² AND has established cardiovascular disease (CVD) and NOT have a history of type 1 nor type II diabetes.”

“Established CVD means history of myocardial infarction, stroke, or symptomatic peripheral arterial disease.”

The footnote attached to Table 4 reads: “Table 4 does not apply to patients with baseline BMI ≥ 27 and established cardiovascular disease for adult patients requesting Wegovy.”

Three implications of the Wegovy CVD pathway:

1. BMI threshold is ≥ 27 (inclusive) — slightly more permissive than Vermont Pattern #41 (BMI > 27 strict-greater). A Kansas Medicaid patient with BMI exactly 27.0 kg/m² would qualify under KS but not VT.
2. The diabetes exclusion routes T1D / T2D patients to the separate T2D pathway — the AOM CV pathway is specifically for non-diabetic patients. A diabetic patient with established CVD qualifies for tirzepatide / dulaglutide / liraglutide under the Diabetes Mellitus Type 2 Agents PA Criteria (which includes an indefinite-approval pathway for CV/renal risk reduction).
3. Symptomatic PAD is required — asymptomatic PAD (abnormal ABI without claudication or rest pain) does NOT qualify under the Wegovy CV pathway. This matches Vermont Pattern #41 language but is more restrictive than several other state Wegovy CV carve-outs.

4. The Table 4 de-listing — Pattern #43 distinctive

Table 4 of the KDHE AOM clinical criteria is the “high-cost-agent” table. Historically, it imposed a stricter BMI threshold (BMI ≥ 40 for adults, or ≥ 140% of the 95th percentile / ≥ 40 kg/m² for adolescents) on enumerated high-priced AOMs — the “severe obesity” gate. Wegovy and Zepbound, as the two highest-list-price branded GLP-1/GIP AOMs at the time of original placement, sat in Table 4.

The KDHE Anti-Obesity Medications PA Form (Rev. 06/2025) Section III question 9 contains the explicit operative note:

“Note: Zepbound (as of 4/1/24) and Wegovy (as of 6/1/25) are currently NOT LISTED in Table 4.”

What this means in practice:

• Effective April 1, 2024: Zepbound moved from Table 4 to the general AOM criteria. A Kansas Medicaid patient at BMI 31 with no Table 2 comorbidity now qualifies for Zepbound under the BMI ≥ 30 adult baseline — rather than being gated at BMI ≥ 40.
• Effective June 1, 2025: Wegovy moved from Table 4 to the general AOM criteria. Same eligibility expansion as Zepbound: BMI ≥ 30 adult baseline, or BMI ≥ 27 with Table 2 comorbidity, or BMI ≥ 27 + established CVD (no diabetes) via the Wegovy CV pathway.
• Saxenda remains in Table 4: the BMI ≥ 40 severe-obesity gate still applies to Saxenda. A Kansas Medicaid patient at BMI 31 seeking Saxenda would NOT qualify under Table 4 criteria.

4.1 Why this matters in the 42-state national context

Between January 2024 and May 2026, four state Medicaid programs publicly dropped or restricted GLP-1 coverage: California (suspended Wegovy/Zepbound for obesity from Medi-Cal pharmacy benefit), New Hampshire (eliminated AOM coverage for adults under Granite Advantage), Pennsylvania (tightened HealthChoices PDL access criteria with effective coverage reduction), and South Carolina (dropped AOM coverage from Healthy Connections Medicaid). Several other states (Massachusetts, Rhode Island) are actively debating sunset proposals.

During this same window, Kansas Medicaid LOOSENED criteria for Wegovy and Zepbound by de-listing both drugs from the Table 4 BMI ≥ 40 gate. This is a counter-cyclical posture worth highlighting:

• Kansas is one of only ~13 state Medicaid programs in the KFF January 2026 active-coverage cohort.
• Kansas is the only state in that cohort whose 2024-2025 policy direction was unambiguously LOOSENING (not maintaining or tightening).
• The Table 4 de-listing was not accompanied by public press release or legislative fanfare — it is documented only in the PA form Section III question 9 note. KDHE clinical-criteria revisions to the underlying AOM document have not been publicly highlighted in the same way that, e.g., Mississippi’s SPA 23-0013 carve-back-in was announced.

4.2 Reverse-engineering the Table 4 milestones

The KDHE AOM clinical criteria document retains the historical Table 4 milestones for Wegovy and Zepbound as if the de-listing were ever reversed:

• Wegovy adults (if Table 4 reactivated): 5% weight loss at initial 12-week milestone; 10% at subsequent milestone; 15% by ≥ 52 weeks
• Zepbound adults (if Table 4 reactivated): 6% weight loss at initial 12-week milestone; 18% at subsequent milestone; 20% by ≥ 52 weeks

Following the de-listing, the operative renewal weight-loss milestone for both Wegovy and Zepbound is the general adult AOM milestone: “The patient has lost a total of 5% of pretreatment weight and maintains the 5% weight loss.” The lower 5% renewal threshold (vs. the would-have-been 10-20% Table 4 milestones) is a meaningful access expansion for patients with weight-loss plateaus or modest weight-loss trajectories.

5. Length of approval and renewal criteria

The KDHE Anti-Obesity Medications PA Form (Rev. 06/2025) defines the length of approval and renewal weight-loss milestones in three tiers.

5.1 Initial approval window

• Wegovy and Zepbound: 12 weeks initial approval
• Saxenda (Table 4 high-cost): 8 weeks initial approval

The 12-week initial window for Wegovy and Zepbound is shorter than the 6-month initial windows used by, e.g., Vermont Pattern #41 for the Wegovy MACE / MASH / Zepbound OSA carve-outs. The shorter window reflects the active titration period for GLP-1/GIP AOMs — allowing KDHE to check early weight-loss trajectory before committing to longer renewals.

5.2 First renewal: 36 months

After the initial 12-week window (Wegovy / Zepbound) or 8-week window (Saxenda), the first renewal extends to 36 months for patients who meet the renewal weight-loss threshold. The 36-month first-renewal window is unusually long compared to peer state Medicaid programs — most states use 12-month renewal windows. The 36-month window reduces administrative burden for patients on stable AOM therapy.

5.3 Subsequent renewals: 12 months

After the 36-month first renewal, subsequent renewals are at 12-month intervals.

5.4 Renewal weight-loss milestones (verbatim)

Adults, non-Table-4 agents (Wegovy + Zepbound following the 2024-2025 de-listing):

“The patient has lost a total of 5% of pretreatment weight and maintains the 5% weight loss.”

Adolescents (≥ 12 to < 18 years):

“> 4% reduction in baseline BMI and maintain the loss.”

Saxenda adults (still in Table 4): 3% weight loss at initial 8 weeks → 7% subsequent → 10% by ≥ 52 weeks.

6. T2D-indicated GLP-1 / GIP-GLP-1 coverage

T2D-indicated GLP-1 and GIP-GLP-1 agents are covered under two related PA pathways. Ozempic, Trulicity, and Victoza are preferred in the GLP-1 RA PDL class (page 20). Mounjaro is covered via the Diabetes Mellitus Type 2 Agents PA Criteria (revised April 16, 2025) Table 1.

The Diabetes Mellitus-Type 2 Agents PA Criteria verbatim:

6.1 HbA1c goal

“Prescriber must provide a prespecified HbA1c goal of one of the following: 6.5%, 7.0%, or 8.0%.”

The three permitted HbA1c goal values match the ADA Standards of Care framework for individualized glycemic targets — 6.5% for tighter goals (e.g., newly diagnosed T2D without hypoglycemia risk), 7.0% as the standard general adult goal, and 8.0% for less-stringent goals (e.g., older adults, complex comorbidities, hypoglycemia history).

6.2 Metformin step therapy

“Have had an adequate trial of generic metformin IR or metformin ER for at least 90 consecutive days of therapy in the past 120 day period, OR Be prescribed generic metformin IR or ER with the requested drug and have an HbA1c ≥ 1.5% of prespecified HbA1c goal determined above, OR Have a contraindication to metformin.”

The metformin step-therapy is a standard Medicaid PA requirement nationally. Three escape valves: prior 90-day trial; concurrent metformin + GLP-1 with HbA1c ≥ 1.5% above goal; metformin contraindication (e.g., reduced eGFR, lactic acidosis history, severe hepatic impairment).

6.3 DPP-4 exclusion

“For all requested glucagon-like peptide-1 (GLP-1) receptor agonist containing agents, patient must not currently be on dipeptidyl peptidase-4 (DPP-4) inhibitor.”

The DPP-4 exclusion reflects the lack of additive glycemic benefit when stacking a DPP-4 inhibitor on a GLP-1 RA — both classes target the incretin pathway. A patient on, e.g., sitagliptin or linagliptin who is initiating a GLP-1 RA must discontinue the DPP-4 inhibitor before or concurrent with GLP-1 initiation.

6.4 Initial approval and renewal

• Initial approval (glycemic control): 6 months
• Initial approval (CV/renal risk reduction): “Indefinite (no renewal required).”
• Renewal (glycemic): 12 months if at HbA1c goal; 6 months if not at goal but achieved ≥ 1% further reduction

The indefinite-approval pathway for CV / renal risk reduction is unusually generous for a state Medicaid program. Patients with established CVD (post-MI, post-stroke, symptomatic PAD) or DKD (diabetic kidney disease with eGFR decline trajectory or proteinuria) qualify for indefinite approval — eliminating the renewal burden that often accompanies T2D pharmacy benefits.

7. KanCare 3.0 MCO architecture (effective January 1, 2025)

KanCare 3.0 launched on January 1, 2025 (NOT July 1, 2025 as some procurement press anticipated). The contract term is January 1, 2025 through December 31, 2027 with two 1-year renewal options through 2029. Per KDHE Civic Alert AID=1104, three MCOs hold the contract.

7.1 Sunflower Health Plan (Centene)

Sunflower Health Plan is a Centene Corporation subsidiary. April 2025 enrollment: 156,864 members (36% of MCO-enrolled population). PA contacts: pharmacy 1-877-397-9526 (phone) / 1-833-645-2740 (fax); medical 1-877-644-4623 (phone) / 1-888-453-4756 (fax). Sunflower publishes a regularly updated KMAP Bulletin series — bulletin 2024-036 specifically addressed GLP-1 weight-loss PA criteria.

7.2 UnitedHealthcare Community Plan of Kansas

UnitedHealthcare Community Plan of Kansas is a UnitedHealth Group subsidiary. April 2025 enrollment: 160,363 members (37% of MCO-enrolled population — the largest of the three MCOs). PA contacts: pharmacy 1-800-310-6826 (phone) / 1-866-940-7328 (fax); medical 1-866-604-3267 (phone).

7.3 Healthy Blue (BCBS of Kansas + Elevance/Anthem JV) — replaced Aetna 12/31/2024

Healthy Blue is a joint venture of Blue Cross Blue Shield of Kansas and Elevance Health (formerly Anthem). It replaced Aetna Better Health of Kansas, whose KanCare contract ended December 31, 2024. April 2025 enrollment: 112,411 members (26% of MCO-enrolled population). PA contacts: pharmacy and medical share PA phone 1-833-838-2595; PA fax 1-877-941-9901 (pharmacy) or 1-877-941-9841 (medical).

The Aetna-to-Healthy-Blue transition affected members whose pharmacy benefits had been administered through Aetna. Members on Aetna with active AOM PA approvals were notified of the transition in late 2024 and had to re-establish their PA under their newly assigned MCO in early 2025. Prescribers should verify with the patient’s current MCO whether prior PA approvals from Aetna were honored or required re-submission.

7.4 KMAP FFS (Gainwell Technologies)

A small subset of KanCare beneficiaries remain on fee-for-service (FFS) rather than MCO assignment — primarily Native American populations, some dual-eligible beneficiaries, and some short-term coverage groups. FFS members use the KMAP MMIS administered by Gainwell Technologies. FFS PA: phone 1-800-933-6593; fax 1-800-913-2229. Provider portal: portal.kmap-state-ks.us/PublicPage.

Effective January 1, 2026 per KMAP Bulletin 25305, all FFS pharmacy paper-claim submissions have been discontinued — all FFS pharmacy claims are now electronic via the Gainwell-administered MMIS.

8. PA submission process end-to-end

The KDHE Anti-Obesity Medications PA Form (Rev. 06/2025) governs all three AOM products (Saxenda, Wegovy, Zepbound). Form URL: kdhe.ks.gov — Anti-Obesity Medications PA Form PDF.

8.1 Step-by-step submission

1. Identify the patient's MCO assignment. Sunflower, UnitedHealthcare, Healthy Blue, or KMAP FFS. Member ID card lists the MCO.
2. Confirm the AOM drug and indication. Saxenda (Section I drug menu — liraglutide), Wegovy (semaglutide), or Zepbound (tirzepatide). For Wegovy: identify whether the patient qualifies under (a) general AOM criteria at BMI ≥ 30 or BMI ≥ 27 + Table 2 comorbidity, OR (b) the Wegovy CV pathway at BMI ≥ 27 + established CVD with no T1D/T2D history.
3. Document the patient's diagnosis with ICD-10 code. For obesity: E66.x. For relevant Table 2 comorbidities: E11.x (T2DM), R73.0x (prediabetes), I10 (hypertension), E78.x (dyslipidemia), I25.x (ischemic heart disease), K76.0 (NAFLD), K76.81 (NASH/MASH), E28.2 (PCOS), G47.33 (OSA), K21.x (GERD), F32.x or F33.x (depression). For Wegovy CV pathway: I63.x (prior cerebral infarction), I21.x or I25.2 (prior MI), I70.21x (symptomatic PAD with claudication).
4. Document BMI to one decimal place. Calculate using the standard formula (weight kg / height m²). For pediatric patients (12-17), reference the Table 3 95th-percentile cutoff for the patient’s age and sex.
5. Attach lifestyle intervention documentation. Patient counseling on chronic weight management (increased physical activity and a reduced calorie diet) plus prescriber attestation that the patient will continue to follow a treatment plan. Documentation should reference specific nutrition counseling or behavioral interventions (e.g., registered dietitian consult, structured weight-loss program, MOVE! veterans program, employer wellness program).
6. Complete Section III question 9 if requesting Wegovy. Indicate whether the Wegovy CV pathway applies (BMI ≥ 27 + established CVD + no diabetes history). If yes, document the qualifying CV event with cardiology consult notes and objective imaging (ECG, cath, MRI). If symptomatic PAD: document both the objective findings (ABI ≤ 0.9, peripheral revascularization, amputation) AND clinical symptoms (claudication, rest pain, non-healing wounds).
7. Reference the Table 4 de-listing if needed. If the PA reviewer queries the BMI threshold for Wegovy or Zepbound, reference the PA Form Section III question 9 note: “Zepbound (as of 4/1/24) and Wegovy (as of 6/1/25) are currently NOT LISTED in Table 4.”
8. Submit to the patient's MCO PA fax line. Healthy Blue 1-877-941-9901 (pharmacy); Sunflower 1-833-645-2740 (pharmacy); UnitedHealthcare 1-866-940-7328 (pharmacy); KMAP FFS 1-800-913-2229.
9. Receive approval / denial decision. Federal 42 CFR 438.210 SLA: 14 calendar days standard / 72 hours expedited. Initial approval window: 12 weeks for Wegovy and Zepbound (8 weeks for Saxenda).
10. At 12 weeks, prepare for first renewal. Document weight loss of 5% from pretreatment weight (adult, non-Table-4 agents) or > 4% reduction in baseline BMI (adolescent). Submit renewal PA — if granted, the first renewal extends 36 months. Subsequent renewals at 12-month intervals.

9. Appeals pathway: two-step (MCO internal → OAH state fair hearing)

Kansas Medicaid uses a two-step appeals pathway combining an MCO internal appeal followed by a state fair hearing before the Office of Administrative Hearings (OAH).

9.1 Step 1 — MCO Internal Appeal

• Filing deadline: 60 calendar days from notice of adverse benefit determination
• Sunflower variant verbatim: “within 60 calendar days of the date on the letter that tells you about the decision, plus three additional calendar days for mailing time.”
• Decision timeframe: 30 calendar days
• Expedited: 72 hours when life, health, or function is jeopardized

Each MCO operates its own internal appeals office:

• Sunflower Health Plan: appeals via member services 1-877-644-4623
• UnitedHealthcare Community Plan of Kansas: appeals via member services 1-866-604-3267
• Healthy Blue of Kansas: appeals via member services 1-833-838-2595

9.2 Step 2 — State Fair Hearing (OAH)

• Filing deadline: 120 calendar days from date of appeal notice (Sunflower fair-hearing page) OR 123 days per the KanCare page (includes 3 mailing days). 120 days is the formal deadline.
• EITPR accelerated path: 30 calendar days from External Independent Third-Party Review notice
• Address: Office of Administrative Hearings, 1020 S. Kansas Ave., Topeka, Kansas 66612
• Fax: 785-296-4848 (requests longer than 20 pages cannot be faxed)
• OAH main phone: 785-296-2433
• Format: Must be in writing
• Procedure: Administrative Law Judge hearing with member, MCO representative, and Medicaid agency or KDADS representative
• Expedited fair-hearing timeline in hours: UNVERIFIED in publicly available OAH or KDHE documentation

The OAH state fair hearing is independent of the MCO and KDHE — an ALJ can overturn an MCO denial. The OAH Medicaid Provider Hearing Request Form is available at oah.ks.gov — Medicaid Provider Request for Admin Hearing.

9.3 Practical denial-recovery strategy

1. First, call the MCO pharmacy benefits helpline. Many denials are documentation deficiencies recoverable via re-submission of the same PA form with additional clinical evidence (more detail on Table 2 comorbidity, more granular BMI to one decimal place, more specific lifestyle-intervention narrative). Verify the denial rationale before initiating an internal appeal.
2. If the denial is substantive (criteria-based), re-submit the PA form with stronger evidence. For BMI-based denials, document BMI to one decimal place and confirm Table 2 comorbidity diagnosis with ICD-10. For Wegovy CV pathway denials, add a cardiology consult note + objective imaging. For pediatric denials, reference the Table 3 95th-percentile cutoff for the patient’s age and sex.
3. If re-submission fails, file the MCO internal appeal within 60 days. Include all original PA documentation plus any new clinical evidence accumulated since the original submission.
4. If internal appeal denies, file an OAH state fair hearing request within 120 days. Mail or fax to OAH at the Topeka address. Reference the specific KDHE AOM criterion that supports your eligibility.
5. Contact a Kansas Medicaid legal-aid organization for free representation if the OAH hearing is contested. Kansas Legal Services (klsinc.org) provides Medicaid representation in some Kansas counties.

10. Recent legislative activity (2025-2026 biennium)

No Kansas legislative bills in the 2025-2026 biennium specifically address GLP-1 or Anti-Obesity Medication Medicaid coverage. This has been verified via LegiScan, KSLegislature.gov, and the Kansas Health Institute (KHI) legislative tracker as of May 15, 2026.

Two Kansas Medicaid bills in the 2025-2026 biennium are relevant context for AOM access even though they do NOT contain GLP-1 provisions.

10.1 HB 2375 — HAWK Act (Healthcare Access for Working Kansans), died in committee

HB 2375 was introduced February 10, 2025 by House Appropriations at Governor Laura Kelly’s request. The bill would have expanded KanCare to adults ages 19-64 at or below 138% FPL with a work requirement. The Kansas Health Institute estimated 28,000 to 120,157 Kansans would have newly enrolled.

Status: Died in committee during the 2025-2026 session. Governor Kelly’s press office (governor.ks.gov) published a HAWK Act announcement at the time of introduction (News & Articles ID=539, Item 56).

The HAWK Act would have materially expanded the population eligible for KanCare AOM coverage by sweeping in the “coverage gap” population (adults above the current 38% FPL threshold but below 138% FPL). Working-poor adults in Kansas without dependents currently fall in this gap — ineligible for KanCare AND ineligible for ACA marketplace subsidies. Many of these adults have obesity (44.6% of adults in households earning under $15,000 have obesity, per CDC) and would have qualified for AOM coverage under KanCare’s BMI ≥ 30 standard.

10.2 SB 363 / HB 2731 — OBBBA-driven Medicaid tightening, veto overridden

SB 363 was introduced January 22, 2026; passed Senate March 5, 2026 (25-12); inserted into HB 2731 in conference. Governor Kelly vetoed; the veto was overridden. Effective July 1, 2026. The legislation reflects federal H.R. 1 (the “One Big Beautiful Bill Act” / OBBBA) Medicaid changes — adding work and eligibility requirements to KanCare.

Status: Enacted, effective July 1, 2026. Contains NO GLP-1 provisions, but tightens overall KanCare eligibility in ways that may reduce the population accessing AOM coverage. The Kansas Health Institute (khi.org) published a comprehensive analysis at khi.org/articles/new-kansas-legislation-and-its-impacts-on-medicaid-and-snap/.

10.3 No GLP-1-specific bills in either chamber

Unlike Maine (LD 480 killed March 20, 2025), Arkansas (HB 1332 died Senate committee May 5, 2025; ACT 628 enacted explicit GLP-1 weight-loss exclusion), Kentucky (SB 65 nullified Beshear’s 907 KAR 23:010 weight-loss amendment), Nebraska (LB907 Indefinitely Postponed), or Vermont (H.765 / S.164 stalled), Kansas has NOT had a GLP-1-specific Medicaid bill in the 2025-2026 biennium. The Table 4 de-listing of Wegovy (June 1, 2025) and Zepbound (April 1, 2024) was an administrative KDHE action, not a legislative action — which means it is also not protected by statute against future tightening.

11. Kansas Medicaid vs. Kansas State Employee Health Plan (SEHP)

A distinctive Kansas-specific cross-program comparison: Kansas Medicaid (KanCare) is MORE generous on AOM access than the Kansas State Employee Health Plan (SEHP).

11.1 SEHP BMI threshold raised to ≥ 35 effective January 1, 2026

Effective January 1, 2026, the Kansas SEHP raised the BMI threshold for GLP-1 coverage for weight management to BMI ≥ 35 (Caremark-administered, not KanCare). The published SEHP policy URL is at sehp.healthbenefitsprogram.ks.gov/glp-1s.

11.2 KanCare retained the more lenient BMI ≥ 30 / ≥ 27 + comorbidity standard

KanCare did NOT raise its BMI threshold in 2026. The general AOM criteria continue at adult BMI ≥ 30 OR BMI ≥ 27 with Table 2 comorbidity. The Wegovy CV pathway continues at BMI ≥ 27 + established CVD.

11.3 The inversion: Medicaid more generous than state-employee plan

A non-pregnant, non-disabled, non-elderly Kansas adult at BMI 32 with hypertension:

• If KanCare: qualifies for Wegovy or Zepbound under the BMI ≥ 27 + hypertension (Table 2) pathway, OR under the BMI ≥ 30 baseline.
• If SEHP: does NOT qualify because SEHP requires BMI ≥ 35.

This inversion is partly explained by the Medicaid drug rebate framework (42 U.S.C. § 1396r-8 mandates large rebates that lower the net cost of branded GLP-1s for Medicaid programs vs. commercial / state-employee plans), and partly by the KDHE clinical posture that has progressively LOOSENED AOM criteria (Table 4 de-listing in 2024-2025) at the same time as the SEHP has tightened them.

Practical implication for Kansans: A state employee whose SEHP no longer covers Wegovy or Zepbound at BMI 32 may, if income- and household-size-eligible, qualify for KanCare and access the same drug under KanCare AOM criteria. This is an unusual cross-program reversal worth knowing about.

12. How Kansas Pattern #43 fits the 50-state series

Kansas Pattern #43 is the first state in the 50-state series identified explicitly as a positive-coverage state that LOOSENED AOM criteria during the 2024-2025 national period of retrenchment. The 43-state series to date documents the following coverage-architecture types:

12.1 Kansas vs. Rhode Island (Pattern #40) — inverse trajectory

Kansas and Rhode Island represent opposite trajectories within the KFF January 2026 13-state active-coverage cohort:

• Direction of travel: Kansas LOOSENED criteria in 2024-2025 (Wegovy + Zepbound de-listed from Table 4). Rhode Island proposes to ELIMINATE coverage entirely by October 1, 2026 (Governor McKee FY2027 Executive Budget Item 028).
• Reader question framing: Kansas patients ask “have I documented BMI ≥ 30 or BMI ≥ 27 with a Table 2 comorbidity?” Rhode Island patients ask “will my existing coverage survive the General Assembly?”
• Architecture: Kansas uses three-MCO architecture (Sunflower / UHC / Healthy Blue) under unified KDHE PDL. Rhode Island uses two-MCO architecture (NHPRI + UHC) under EOHHS FFS PDL floor.
• Expansion status: Kansas is a non-expansion state. Rhode Island expanded under ACA effective January 1, 2014.

12.2 Kansas vs. Vermont (Pattern #41) — opposite categorical posture

Kansas and Vermont sit on opposite ends of the categorical-coverage continuum:

• Baseline obesity coverage: Kansas covers Wegovy and Zepbound at adult BMI ≥ 30 (no carve-out gymnastics required). Vermont excludes baseline AOM under a PDL Disclaimer block bundling weight-loss with fertility, cosmetic, and hair-growth drugs.
• Carve-out architecture: Kansas has no need for dedicated PA forms for CV / MASH / OSA because those indications are subsumed under the general AOM Table 2 comorbidity pathway. Vermont operationalizes three FDA-label carve-outs via dedicated PA forms (Wegovy MACE, Wegovy MASH, Zepbound OSA).
• Architecture: Kansas is MCO-dominant (three MCOs). Vermont is FFS-only via Optum PBM (CMS Managed Care state profile lists VT under PCCM, not capitated MCOs).
• Expansion status: Kansas non-expansion. Vermont expanded under ACA effective January 1, 2014.

12.3 Kansas vs. Mississippi (Pattern #35) — both non-expansion positive-coverage

Kansas and Mississippi are the two non-expansion positive-coverage states in the series so far. Both demonstrate that non-expansion status does not preclude generous Medicaid AOM coverage. Key differences:

• Mechanism: Mississippi operationalized AOM coverage via SPA 23-0013 (a formal State Plan Amendment carve-back-in from a prior exclusion posture). Kansas has covered AOMs continuously since the original KDHE AOM clinical criteria document (September 14, 2007) and never executed a CMS-approved SPA carve-back-in.
• Pediatric pathway: Both states cover Wegovy for adolescents ages 12+ via CDC growth-chart 95th-percentile BMI cutoffs. Kansas Table 3 and Mississippi’s PA-form table are structurally similar.
• Geography: Mississippi is in the southern non-expansion cluster (AL, FL, GA, MS, SC, TN). Kansas is in the central-plains non-expansion cluster (KS, TX, WI, WY).

13. UNVERIFIED items — flagged honestly

Per Weight Loss Rankings’ YMYL 125% accuracy standard, the following items are flagged as UNVERIFIED rather than fabricated. These are gaps in the publicly available Kansas Medicaid primary sources that readers should verify independently.

1. KMAP FFS PA adjudication SLA in days for standard vs. expedited. Federal 42 CFR 438.210 imposes 14 calendar days standard / 72 hours expedited as the floor. The KDHE-specific SLA (e.g., shorter internal targets) is not published in the readable KMAP or KanCare materials.
2. KDHE Zepbound-OSA-specific bulletin post FDA December 2024. No standalone Zepbound-OSA carve-out bulletin has been located. OSA is listed as a Table 2 weight-related comorbidity, so a Kansas Medicaid patient with BMI ≥ 27 and documented OSA qualifies for Zepbound under the standard AOM pathway — but a dedicated OSA PA criterion (e.g., independent of BMI) has not been documented.
3. KDHE Wegovy-MASH-specific bulletin post FDA August 2025. No standalone Wegovy-MASH carve-out bulletin has been located. NAFLD/NASH is listed as a Table 2 weight-related comorbidity. A Kansas Medicaid patient with BMI ≥ 27 and documented NASH/MASH qualifies for Wegovy under the standard pathway — but a dedicated MASH PA criterion (e.g., F2/F3 fibrosis confirmation pathway as in Vermont Pattern #41 or West Virginia Pattern #36) has not been documented.
4. OAH expedited fair-hearing timeline in hours. The standard 120-day filing deadline is documented, but the expedited fair-hearing timeline (e.g., 3 working days) is not published in readable OAH or KDHE materials.
5. Complete ICD-10 list accepted on AOM PA Form. The PA form uses free-text fields for diagnosis documentation rather than a checkbox list of accepted ICD-10 codes. Prescribers should reference standard codes (E66.x for obesity, E11.x for T2DM, etc.) and provide enough clinical detail to support the BMI / Table 2 / Table 3 eligibility category.

If you encounter any of these gaps in practice, please contact us with the documentation and we will update this article with verified primary-source language.

14. What Kansas Medicaid beneficiaries should do right now

If you have BMI ≥ 30 (adult): you qualify for Wegovy or Zepbound under the general AOM pathway after the Table 4 de-listing. Ask your prescriber to submit the KDHE Anti-Obesity Medications PA Form (Rev. 06/2025) to your MCO’s pharmacy PA fax line (Sunflower 1-833-645-2740; UHC 1-866-940-7328; Healthy Blue 1-877-941-9901). Initial approval is 12 weeks; first renewal is 36 months; subsequent renewals 12 months. Renewal weight-loss milestone: 5% from pretreatment weight (and maintained).

If you have BMI ≥ 27 with a Table 2 comorbidity: you qualify under the general AOM pathway via the BMI ≥ 27 + comorbidity threshold. Table 2 comorbidities include T2DM, prediabetes, HTN, dyslipidemia, CVD, NAFLD/NASH, PCOS, OSA, GERD, depression, infertility, cancer, OA, asthma, urinary stress incontinence, and male hypogonadism. Document the qualifying comorbidity with the relevant ICD-10 code in the PA submission.

If you have BMI ≥ 27 + established CVD (no diabetes): you qualify for Wegovy specifically under the CV pathway. Document the qualifying CV event (prior MI, stroke, or symptomatic PAD) with cardiology consult notes and objective imaging. For symptomatic PAD, document both the objective findings AND clinical symptoms (claudication, rest pain, non-healing wounds).

If you are an adolescent ages 12-17: you qualify for Wegovy or Saxenda if your BMI is at or above the 95th percentile for age and sex per Table 3. Zepbound is restricted to ≥ 18 (matches FDA label). Ensure your BMI is calculated to one decimal place using the standard formula and that your prescribing pediatrician or adolescent medicine specialist references Table 3 in the PA submission narrative.

If you have T2D: the standard T2D pharmacy pathway applies via the Diabetes Mellitus Type 2 Agents PA Criteria. Ozempic, Trulicity, and Victoza are preferred. Mounjaro is covered via Table 1 of the T2D criteria document. Renewal: 12 months if at HbA1c goal (6.5%, 7.0%, or 8.0%); 6 months if not at goal but with ≥ 1% further reduction. Indefinite approval pathway available for CV/renal risk reduction.

If you are a state employee transitioning off SEHP at BMI 32: the Kansas SEHP raised its GLP-1 BMI threshold to ≥ 35 effective January 1, 2026, but KanCare retained the more lenient BMI ≥ 30 / ≥ 27 + comorbidity standard. If you are income- and household-size-eligible, KanCare may cover Wegovy or Zepbound at BMI 32 where SEHP no longer does.

If your PA is denied: do not give up after the first denial. Call your MCO pharmacy benefits helpline to verify denial rationale — many denials are documentation deficiencies recoverable via re-submission. If the denial is criteria-based, re-submit with stronger clinical evidence. If re-submission fails, file an MCO internal appeal within 60 calendar days. If the internal appeal fails, file an OAH state fair hearing request within 120 days. The OAH state fair hearing is independent of the MCO and KDHE — an ALJ can overturn an MCO denial.

If you do not qualify for KanCare (because Kansas has not expanded Medicaid and you fall in the coverage gap): consider (1) NovoCare Wegovy cash-pay at $199-$349/month (HD pen at $399/month; oral semaglutide tablets at $149/month per the May 15, 2026 NovoCare verification); (2) LillyDirect Zepbound vials at $299-$699/month; (3) LillyDirect Foundayo (orforglipron, FDA-approved April 1, 2026) at $149/month self-pay; (4) Novo Nordisk PAP and Lilly Cares patient assistance programs; (5) LegitScript-approved compounded telehealth (with the FDA compounding-resolved caveats for semaglutide and tirzepatide).

Related coverage

• Hawaii Med-QUEST GLP-1 Coverage (Pattern #50 CAPSTONE / SERIES COMPLETE) — inverse coverage trajectory in the 50-state series: where KS LOOSENED AOM criteria 2024-2025 by de-listing Wegovy + Zepbound from Table 4 (BMI ≥ 40 severe-obesity gate eliminated) under KanCare 3.0 three-MCO architecture, HI codifies a categorical AOM exclusion at the AlohaCare formulary level verbatim “Drugs for weight loss, erectile dysfunction, infertility, and cosmetic purposes are not covered” but with an active 2026 Regular Session bipartisan reversal bill SB 3195 (Sen. Kurt Fevella R-Ewa Beach) that would scrap the exclusion AND prohibit PA. HI operates 5-MCO mandatory managed care under 32-year continuous 1115 demonstration (CMS 11-W-00001/9 since August 1, 1994). HI is Medicaid-expansion state at 138% FPL; KS remains one of 10 non-expansion states. HI 27.0% adult obesity rate (2nd-lowest in US) masks PMID 39574878 NHPI vs White tirzepatide adjusted OR 0.4. Pattern #50 closes the 50-state series
• Alaska Medicaid GLP-1 Coverage (Pattern #49) — opposite coverage posture: where KS LOOSENED AOM criteria 2024-2025 (Wegovy + Zepbound de-listed from Table 4) under KanCare 3.0 capitated MCO architecture, AK operates a categorical AOM exclusion by ABSENCE from the March 1, 2026 PDL (Wegovy / Zepbound / Saxenda absent from any of the 42 PDL pages); AK is FFS-only with no MCOs, contrasting with KanCare 3.0’s three-MCO architecture; AK is a Medicaid-expansion state (Gov. Walker September 1, 2015) while KS remains non-expansion; AK’s 100% FMAP Tribal Health Compact (229+ federally recognized tribes) and largest-US-geography are unique in the series
• Delaware Medicaid GLP-1 Coverage (Pattern #42) — positive-coverage stable state with unified DMAP PDL across 3 MCOs (Wegovy + Saxenda preferred; Zepbound clinical-exception pathway); §1115 Diamond State Health Plan extended through December 31, 2028
• Wyoming Medicaid GLP-1 Coverage (Pattern #47) — inverse-trajectory non-expansion peer: where KS LOOSENED AOM criteria 2024-2025 (Wegovy + Zepbound de-listed from Table 4 under capitated KanCare 3.0 MCO architecture), WY codifies a categorical “Anorexiant products” exclusion in the WDH Pharmacy Services Manual Revision 27 (eff. April 15, 2026) page 8 with three FDA-label carve-ins (Wegovy SELECT/CV verbatim FDA label adoption, Wegovy MASH, Zepbound OSA — LEAST restrictive OSA carve-in in categorical cohort with no CPAP prerequisite); WY uses FFS-only architecture with WYhealth Care Management Entity (not capitated) + OptumRx as pharmacy benefit administrator after April 15, 2026 migration; smallest US state by population (~580K, ~59,714 enrollment per CMS Oct 2025); no AOM legislation 2024-2026; 2026 expansion defeated 7-23 and 5-26
• North Dakota Medicaid GLP-1 Coverage (Pattern #44) — inverse-trajectory comparison: where KS LOOSENED criteria 2024-2025 (Wegovy + Zepbound de-listed from Table 4), ND legislators rejected analogous coverage 12-81 on the House floor (02/12/2025) — the most decisive legislative no-vote on Medicaid GLP-1 coverage in the 43-state series; ND is the middle-ground “covered for everything except obesity” state (covers Wegovy MACE + MASH + Zepbound OSA + antipsychotic-induced + Imcivree + low-cost AOMs but excludes standalone-obesity Wegovy/Zepbound/Saxenda); FFS-dominant + BCBSND-only expansion (1915(b) waiver)
• South Dakota Medicaid GLP-1 Coverage (Pattern #45) — opposite coverage posture in the small-Medicaid-state cohort: where KS COVERS Wegovy + Zepbound for obesity under KanCare 3.0 capitated MCO architecture and LOOSENED criteria 2024-2025, SD operates a functional AOM exclusion by ABSENCE under FFS-only DSS architecture (no codified categorical sentence; the OptumRx SD-specific GLP-1 PA form pre-codes ONLY T2D); ballot-initiative expansion via Amendment D 2022 (SD) vs. KS still one of 10 non-expansion states; HJR 5001 referred Constitutional Amendment I (90% FMAP trigger) to the Nov 3, 2026 ballot
• Idaho Medicaid GLP-1 Coverage (Pattern #48) — legislative-trajectory contrast to KS: where KS LOOSENED AOM criteria 2024-2025 (Wegovy + Zepbound de-listed from Table 4) under a non-expansion KanCare 3.0 capitated MCO architecture, ID’s legislative trajectory is in the opposite direction (HB 138 defeated 2025, HB 345 signed MCO-by-2030, HB 913 signed April 11, 2026 work-requirements-by-2027) and ID does NOT cover AOMs for obesity. Both KS and ID use OAH (neutral / independent ALJs who do not work for the agency that issued the denial) as the hearing body. ID’s exclusion is OPERATIONAL not statutory — IDAPA 16.03.09.662 does NOT enumerate anti-obesity drugs as an excluded class, meaning the bar to administrative carve-back-in is LOWER than statutory states; but state-employee plan dropped GLP-1 obesity coverage Nov 1, 2025 creates political compounding
• Vermont Medicaid GLP-1 Coverage (Pattern #41) — categorical AOM exclusion (weight-loss + fertility + cosmetic + hair-growth bundle) with three FDA-label carve-outs (Wegovy MACE + Wegovy MASH + Zepbound OSA) under FFS-only Optum-administered pharmacy benefit
• Rhode Island Medicaid GLP-1 Coverage (Pattern #40) — inverse trajectory: active coverage with governor-proposed October 1, 2026 sunset (Kansas LOOSENED criteria during the same window when RI proposes to ELIMINATE coverage)
• Maine MaineCare GLP-1 Coverage (Pattern #39) — categorical exclusion with NO Wegovy MASH carve-out; LD 480 killed March 20, 2025
• Nebraska Medicaid GLP-1 Coverage (Pattern #38) — categorical exclusion with 45-74 age gate + 6-month MASH prerequisite; LB907 Indefinitely Postponed
• Utah Medicaid GLP-1 Coverage (Pattern #37) — legislative pilot-program coverage with 6/30/2026 sunset of in-lab attended PSG carve-out
• West Virginia Medicaid GLP-1 Coverage (Pattern #36) — categorical exclusion with Wegovy CV + Zepbound OSA + Wegovy MASH carve-outs via WVU RDTP
• Mississippi Medicaid GLP-1 Coverage (Pattern #35) — the other non-expansion positive-coverage state in the series; SPA 23-0013 carve-back-in with pediatric ages 12+ pathway
• Arkansas Medicaid GLP-1 Coverage (Pattern #34) — three-program-bifurcated regulatory exclusion with ACT 628 explicit weight-loss exclusion enacted January 1, 2026
• 50-state Medicaid GLP-1 coverage map — full series overview with pattern taxonomy
• GLP-1 insurance coverage hub — Medicare, Medicaid, and commercial coverage landscape
• GLP-1 insurance dropped coverage appeal playbook — denial-recovery patterns applicable across states

Primary sources

1. KDHE Anti-Obesity Medications PA Form (Rev. 06/2025)
2. KDHE Anti-Obesity Agents Clinical PA Criteria — Initial 09/14/2007; Rev. 01/17/2024
3. Kansas Medicaid Preferred Drug List — Last Updated 05/01/2026
4. KS Non-Preferred PDL PA Criteria — Rev. 07/15/2025
5. KS Diabetes Mellitus Type 2 Agents PA Criteria — Rev. 04/16/2025
6. KDHE Preferred Drug List Hub
7. KDHE General Clinical Prior Authorization Index
8. KDHE Civic Alert AID=1104 (KanCare 3.0 launch)
9. Kansas Medical Assistance Report FY2026
10. KanCare State Fair Hearings
11. KanCare Appeals & Fair Hearings Hub
12. Sunflower Health Plan State Fair Hearing
13. Sunflower KMAP Bulletin 2024-036 (GLP-1 Weight Loss PA)
14. Office of Administrative Hearings (Kansas)
15. OAH Medicaid Provider Hearing Request Form
16. Kansas HB 2375 (HAWK Act, died in committee)
17. Governor Kelly HAWK Act Press Release
18. KFF Medicaid Coverage of and Spending on GLP-1s (January 16, 2026)
19. Kansas Health Institute — New Kansas Legislation Impacts (HB 2731 / SB 363)
20. KHI — Medicaid Expansion Updated Estimates (post-OBBBA)
21. KHI — 2025 Kansas Legislative Recap
22. KanCare Spending & Enrollment Reports
23. KMAP Provider Portal (Gainwell)
24. Kansas SEHP GLP-1 Policy (BMI ≥ 35 effective January 1, 2026)
25. Stateline — States Dropping GLP-1 Coverage (April 30, 2026)