Louisiana Medicaid (Healthy Louisiana) GLP-1 Coverage 2026: Pattern #28 — Expansion-State Dual-PDL-Listed Carve-Out + ULM College of Pharmacy FFS PA + SB 433 Senate 31-0 Expansion Push

What you need to know (TL;DR)

Louisiana Medicaid — branded Healthy Louisiana — is the 28th state documented in the 50-state Medicaid GLP-1 series and the most editorially distinctive of the southern states: it is the Deep South’s first Medicaid expansion state, it is the only state in the series to enumerate both Wegovy AND Zepbound on the same Single PDL with explicit PATIENT TREATMENT AGREEMENT requirements, its fee-for-service PA is administered by the University of Louisiana at Monroe (ULM) College of Pharmacy (only the second state-university-administered FFS PA infrastructure in the series), and it has the strongest single-chamber legislative-expansion momentum in the series right now via SB 433.

The headline coverage finding: Healthy Louisiana DOES cover Wegovy and Zepbound — but only for FDA-label-restricted indications, not for chronic weight management:

• Wegovy (semaglutide injection/tablet): Covered for cardiovascular (CV) risk reduction only — age ≥ 45, BMI ≥ 27, established CVD (prior MI, prior stroke, or peripheral arterial disease), no T1DM or T2DM, no concurrent GLP-1, plus optimized pharmacotherapy + lifestyle counseling. Initiation approval 6 months; continuation 3–6 months gated on ≥ 5% weight loss.
• Zepbound (tirzepatide): Covered for moderate-to-severe obstructive sleep apnea (OSA) only — age ≥ 18, AHI ≥ 15 on polysomnography within previous 12 months, no central or mixed sleep apnea, concurrent PAP therapy or documented non-adherence, BMI ≥ 30, no T1DM or T2DM, no concurrent GLP-1. Initiation approval 6 months; continuation 3–12 months gated on ≥ 5% weight loss AND documented decrease in AHI and OSA symptoms.
• Xenical (orlistat): Covered on the Single PDL (page 68) with AL, DX, RX, QL point-of-sale edits. The LDH Provider Manual Chapter 37 Section 37.5.4 expressly carves orlistat out of the anorectics exclusion. This is the only general-obesity drug with a standing LDH coverage pathway for the broader adult population.

No Wegovy for chronic weight management without CVD. No Zepbound for chronic weight management without OSA. No Saxenda, Qsymia, Contrave, phentermine, Imcivree, or Foundayo on the LDH PDL.

The PBM landscape changed dramatically effective October 1, 2025: Louisiana terminated its single-PBM model (Prime Therapeutics, May 2019 – September 30, 2025) and pivoted to a 5-PBM-per-MCO diversified model — the only mid-2025 PBM restructuring in the 28-state series. Fee-for-Service claims continue through Gainwell Technologies; each of the five Healthy Louisiana MCOs (Aetna Better Health, AmeriHealth Caritas Louisiana, Healthy Blue, Humana Healthy Horizons, Louisiana Healthcare Connections) now contracts with its own PBM. All five MCOs and FFS use the same LDH Single PDL and LDH Clinical Authorization Criteria.

The most time-sensitive news: Senate Bill 433 (Sen. Gerald Boudreaux, D-Lafayette) passed the Louisiana Senate 31-0 on April 29, 2026 — unanimous and bipartisan, the strongest single-chamber legislative-expansion vote for any GLP-1 state bill in the 28-state series. The bill is now pending in the House Health and Welfare Committee. If enacted and signed, the effective date is January 1, 2027. LDH Secretary Bruce Greenstein has publicly endorsed it. SB 433 is NOT yet law; this article documents the current exclusion framework.

The LDH Provider Manual § 37.5.4 anti-obesity exclusion and the orlistat carve-in

The federal foundation is 42 U.S.C. § 1396r-8(d)(2)(A), Section 1927(d)(2)(A) of the Social Security Act, which authorizes states to exclude “agents when used for anorexia, weight loss, or weight gain” from Medicaid coverage. Louisiana has partially invoked this authority — it excludes general chronic-weight-management coverage but operationally carves in three drugs via its PDL + Clinical Authorization Criteria mechanism. The verbatim federal text:

“(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.”
Source: 42 U.S.C. § 1396r-8(d)(2)(A)

At the state level, the operative exclusion lives in the Louisiana Medicaid Program Provider Manual, Chapter 37 “Pharmacy Benefits Management Services,” Section 37.5.4 “Non-Covered Services.” Verified via direct PDF fetch from lamedicaid.com/provweb1/manuals/pharm_benefits_manual.pdf, 2026-05-10.

Verbatim Section 37.5.4 Non-Covered Services — Drugs Excluded From Coverage (excerpt):

“The Medicaid program excludes the following drugs and/or therapeutic categories from coverage:

Anorexics – Medicaid does not reimburse for anorexics with the exception of orlistat;
Note: Refer to Section 37.5.6 for program restrictions.

Compounded prescriptions (mixtures of two or more ingredients; the individual drugs will continue to be reimbursed);

Cosmetic drugs;

Cough and cold preparations;

Drug Efficacy Study Implementation (DESI) Drugs refer to those drugs that the FDA has proposed to withdraw from the market because they lack substantial evidence of effectiveness;

Erectile dysfunction drugs;

Experimental drugs;

Fertility drugs when used for fertility treatment;”
Source: LDH Medicaid Pharmacy Benefits Management Provider Manual, Chapter 37, Section 37.5.4 (Issue Date 12/01/05; rev. 04/01/11). lamedicaid.com/provweb1/manuals/pharm_benefits_manual.pdf

The sentence “Medicaid does not reimburse for anorexics with the exception of orlistat” is the single most citable line in the entire Louisiana regulatory framework. It establishes the categorical exclusion AND the orlistat carve-in in one sentence. The phrase “anorexics” here is the traditional pharmacological term for appetite suppressants / weight-loss agents — not a reference to the eating disorder anorexia nervosa.

A complementary provision appears in Section 37.7.5 (Medicare Part D Outpatient Drug Coverage — Medicaid Coverage for Excluded Part D Drugs), which confirms the orlistat-only AOM coverage position:

“The following excluded drugs are covered by Louisiana Medicaid unless they are covered by Medicare Part B or Part D.

Benzodiazepines
Barbiturates
Agents when used for anorexia, weight loss or weight gain (Orlistat only);”
Source: LDH Provider Manual Chapter 37, Section 37.7.5

One critical distinction from other states in the series: Louisiana does not have a Louisiana Administrative Code (LAC) Title 50 provision explicitly excluding weight-loss agents at the regulatory-code level. Unlike Alabama (Ala. Admin. Code r. 560-X-16-.01(2)(b)), Indiana (405 IAC 5-24-3(b)(1)), or Illinois (89 IAC § 140.441(b)), Louisiana’s exclusion is operationalized through the LDH Pharmacy Benefits Management Provider Manual Chapter 37 — a quasi-regulatory administrative document. The Provider Manual is not a promulgated Louisiana Administrative Code provision. This matters for appeals: arguments grounded in regulatory-amendment procedures are less applicable in Louisiana than in states with an explicit IAC or KAR-level exclusion rule.

The operational mechanism designating Wegovy (for CV) and Zepbound (for OSA) as covered drugs notwithstanding the categorical exclusion is the LDH Single PDL + standalone Clinical Authorization Criteria PDFs — Wegovy is excluded as a weight-loss drug unless prescribed for CV risk reduction with FDA-label criteria; Zepbound is excluded as a weight-loss drug unlessprescribed for moderate-to-severe OSA with FDA-label criteria.

The LDH Single PDL: Wegovy + Zepbound + Xenical with Patient Treatment Agreement

The Louisiana Medicaid Preferred Drug List (PDL) / Non-Preferred Drug List (NPDL) effective January 1, 2026 (updated 04/01/26), verified via direct PDF fetch from ldh.la.gov/assets/healthyla/pharmacy/pdl.pdf, is the operational coverage anchor for Wegovy, Zepbound, and Xenical. The PDL header states:

“Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL)

• The PDL applies to all individuals enrolled in Louisiana Medicaid, including those covered by one of the managed care organizations (MCOs) and those in the Fee-for-Service (FFS) program.

• The PDL is a list of over 100 therapeutic classes reviewed by the Pharmaceutical & Therapeutics (P&T) committee. With the exception of excluded drug classes listed in the provider manual, medications that are not included in this PDL are almost always covered without the requirement of prior authorization.

• Medications listed as non-preferred are available through the prior authorization (PA) process. See chart below for PA contact information. All MCOs and FFS use the same PA Request Form.”
Source: Louisiana Medicaid Single PDL, Page 1 Header (eff. Jan 1, 2026; updated 04/01/26). ldh.la.gov/assets/healthyla/pharmacy/pdl.pdf

The PA contact information on PDL Page 1 (effective 10/01/2025) reflects the post-PBM-transition MCO phone numbers:

“Pharmacy Prior Authorization Information Phone Numbers for MCOs and FFS
Effective 10/01/2025

Aetna Better Health of Louisiana – 1-855-242-0802
AmeriHealth Caritas Louisiana – 1-800-684-5502
Healthy Blue – 1-844-521-6942
Humana – 1-800-555-2546
LA Healthcare Connections – 1-866-595-8133

Fee-for-Service (FFS) Louisiana Legacy Medicaid 1-866-730-4357”
Source: LDH Single PDL Page 1, PA Contact Information Table (eff. 10/01/2025).

Wegovy, Zepbound, and Xenical appear on PDL Pages 67–68 under “Additional Agents That Have Point-of-Sale (POS) Requirement(s).” These entries are verbatim:

Wegovy entry:
“Wegovy® (Semaglutide) Injection/Tablet    CL, QL, TD
PATIENT TREATMENT AGREEMENT”

Zepbound entry:
“Zepbound™ (Tirzepatide)    AL, DX, TD, QL
PATIENT TREATMENT AGREEMENT”

Xenical entry:
“Xenical® (Orlistat)    AL, DX, RX, QL”
Source: LDH Single PDL Pages 67–68 (eff. Jan 1, 2026; updated 04/01/26).

The PDL Page 66 legend defines each POS edit code:

“Additional Agents That Have Point-of-Sale (POS) Requirement(s)

AL – Age Limit
CL – Additional Clinical Information is Required
DX – Diagnosis Code Requirement
PA – Prior Authorization
QL – Quantity Limit
RX – Specific Prescription Requirement
TD – Therapeutic Duplication”
Source: LDH Single PDL Page 66 Legend.

Interpreting the POS edits for each drug:

• Wegovy: CL + QL + TD + PATIENT TREATMENT AGREEMENT. CL means “Additional Clinical Information is Required” — this is what triggers the separate Wegovy Clinical Authorization Criteria form. QL = Quantity Limit (maintenance dose 1.7mg or 2.4mg weekly). TD = Therapeutic Duplication restriction (no concurrent GLP-1 or semaglutide). PATIENT TREATMENT AGREEMENT = signed treatment agreement submitted with initiation request.
• Zepbound: AL + DX + TD + QL + PATIENT TREATMENT AGREEMENT. AL = Age Limit (18+). DX = Diagnosis Code Requirement (OSA ICD-10-CM code required at point of sale). TD = Therapeutic Duplication restriction (no concurrent GLP-1 or tirzepatide). QL = Quantity Limit (maintenance dose 10mg or 15mg weekly). PATIENT TREATMENT AGREEMENT = signed treatment agreement submitted with initiation request.
• Xenical: AL + DX + RX + QL. Age Limit + Diagnosis Code Requirement + Specific Prescription Requirement + Quantity Limit. No Patient Treatment Agreement for orlistat — the General Adult obesity criteria are lighter than the MACE/OSA carve-out criteria.

Louisiana is the only state in the 28-state series to enumerate BOTH Wegovy AND Zepbound on the same Single PDL with explicit “PATIENT TREATMENT AGREEMENT” notation. Compare: Alabama lists Zepbound on its PDL (Incretin Mimetics class, OSA-only footnote ^) but Wegovy is off-PDL (Cardiac Agents PA Form 369 only). Kentucky administers both via MedImpact PA criteria PDFs without PDL enumeration. Oklahoma uses DUR-Board criteria PDFs without a Single PDL therapeutic-class table. Louisiana’s dual-PDL enumeration with Treatment Agreement notation is operationally the most transparent architecture in the southern-state carve-out cluster.

Wegovy CV PA criteria — initiation and continuation (verbatim)

The Louisiana Medicaid Semaglutide (Wegovy®) Clinical Authorization Criteria were verified via direct PDF fetch from ldh.la.gov/assets/medicaid/PharmPC/5.15.24/Wegovy.05072024.pdf, 2026-05-10. Policy created April 2024; Implementation Date July 2024.

The document header states:

“Louisiana Medicaid
Semaglutide (Wegovy®)

The Louisiana Uniform Prescription Drug Prior Authorization Form should be utilized to request clinical authorization for Wegovy®. For initiation of therapy requests, the Semaglutide (Wegovy®) Treatment Agreement for Louisiana Medicaid Recipients must be completed as instructed, and submitted with the request form.

Additional Point-of-Sale edits may apply.
By submitting the authorization request, the prescriber attests to the conditions available HERE.”
Source: LDH Wegovy Clinical Authorization Criteria, Document Header (April 2024 / July 2024 implementation). ldh.la.gov/assets/medicaid/PharmPC/5.15.24/Wegovy.05072024.pdf

Initiation of Therapy — Verbatim Approval Criteria

“Approval Criteria for Initiation of Therapy

• The recipient is 45 years of age or older on the date of the request; AND
• The recipient has a documented Body Mass Index (BMI) of 27 kg/m² or greater (date and results of the most recent BMI calculation are stated on the request); AND
• The recipient has established cardiovascular disease based on at least ONE of the following that is stated on the request:
   o Prior myocardial infarction; OR
   o Prior stroke (ischemic or hemorrhagic stroke); OR
   o Peripheral arterial disease, as evidenced by one of the following, which is stated on the request:
      ▪ Intermittent claudication with ankle-brachial index (ABI) less than 0.85 (at rest); OR
      ▪ History of peripheral arterial revascularization procedure; OR
      ▪ Amputation due to atherosclerotic disease; AND
• The recipient does not have type 1 or type 2 diabetes; AND
• The recipient will not use this medication with other semaglutide products or with any other GLP-1 receptor agonists; AND
• The prescriber states on the request that semaglutide treatment will be used as adjunct treatment to standard of care therapy, which includes, but is not limited to:
   o Optimized pharmacotherapy for established cardiovascular disease; AND
   o Individualized healthy lifestyle counseling; AND
   o Behavioral modification including a reduced calorie diet and increased physical activity.

Duration of approval for initiation of therapy: 6 months”
Source: LDH Wegovy Clinical Authorization Criteria, Initiation of Therapy Approval Criteria (April 2024 / July 2024).

Continuation of Therapy — Verbatim Approval Criteria

“Approval Criteria for Continuation of Therapy

• ONE of the following is true:
   o The recipient is currently receiving this medication, as evidenced by paid pharmacy claims; OR
   o Documentation provided with the request indicates that the recipient met the initial approval criteria and has received this medication for at least 30 days; AND
• ONE of the following is true and is stated on the request:
   o The recipient lost ≥ 5 percent of baseline body weight OR has continued to maintain their initial 5 percent weight loss (Documentation of the recipient's baseline weight prior to initiation of therapy and the recipient's current weight, including the date the weights were taken must be submitted); OR
   o The recipient DID NOT reach or maintain the weight loss goal of at least 5 percent and clinical justification for continuation of current therapy is provided; AND
• The prescriber states on the request that semaglutide treatment will be used as adjunct treatment to standard of care therapy, which includes, but is not limited to:
   o Optimized pharmacotherapy for established cardiovascular disease; AND
   o Individualized healthy lifestyle counseling; AND
   o Behavioral modification including a reduced calorie diet and increased physical activity; AND
• The request is for a maintenance dose of 1.7mg or 2.4mg once weekly (if appropriate based on recipient's current titration schedule).

Duration of approval for continuation / maintenance of therapy: 3–6 months
• For weight loss > 5%, approve for an additional 6 months.
• For weight loss < 5%, approve for 3 months if clinical justification is provided as to why this weight loss goal was not reached.

If previous duration of approval was for 3 months:
• For weight loss > 5%, approve for an additional 6 months.
• For weight loss < 5%, do not approve.

Note: If the recipient is unable to tolerate a 1.7mg weekly maintenance dose, the medication should be discontinued.”
Source: LDH Wegovy Clinical Authorization Criteria, Continuation of Therapy Approval Criteria (April 2024 / July 2024).

The T1DM/T2DM exclusion: structurally narrower than the SELECT trial

The criterion “The recipient does not have type 1 or type 2 diabetes” deserves explicit attention. The SELECT trial (NCT03574597 — Semaglutide Effects on Heart Disease and Stroke in Patients With Overweight or Obesity) — the pivotal trial supporting the FDA’s March 8, 2024 Wegovy cardiovascular indication — enrolled adults without diabetes at baseline. The LDH criteria align with this trial design: the CV-only carve-out is explicitly for non-diabetic Louisianians. The FDA Wegovy label itself does not categorically exclude T2DM patients from the CV indication — but Louisiana’s PA criteria do.

The operational consequence: A Louisiana Medicaid recipient with established CVD, a BMI of 30, age 50, and type 2 diabetes cannot access Wegovy for cardiovascular risk reduction under the LDH PA criteria — even though the SELECT trial rationale applies to their cardiovascular risk profile. They would instead be channeled to Ozempic, Trulicity, or Mounjaro under the LDH GLP-1 Agonist diabetes criteria. This is a structurally important limitation that prescribers should understand before submitting a PA request.

The Wegovy criteria also reference the SELECT trial and the March 2024 Wegovy label in their verbatim References section, confirming LDH adopted Wegovy CV-only coverage approximately four months after the FDA SELECT-based label expansion (FDA action March 8, 2024 → LDH policy created April 2024 → implementation July 2024).

Zepbound OSA PA criteria — initiation and continuation (verbatim)

The Louisiana Medicaid Tirzepatide (Zepbound®) Clinical Authorization Criteria were verified via direct PDF fetch from ldh.la.gov/assets/medicaid/PharmPC/9_26_25/Zepbound.06052025.pdf, 2026-05-10. Policy created June 2025; Implementation Date January 2026.

“Louisiana Medicaid
Tirzepatide (Zepbound®)

The Louisiana Uniform Prescription Drug Prior Authorization Form should be utilized to request clinical authorization for tirzepatide (Zepbound®). For initiation of therapy requests, the Tirzepatide (Zepbound®) Treatment Agreement for Louisiana Medicaid Recipients must be completed as instructed and submitted with the request form.

Additional Point-of-Sale edits may apply.
By submitting the authorization request, the prescriber attests to the conditions available HERE.”
Source: LDH Zepbound Clinical Authorization Criteria, Document Header (June 2025 / January 2026 implementation). ldh.la.gov/assets/medicaid/PharmPC/9_26_25/Zepbound.06052025.pdf

Initiation of Therapy — Verbatim Approval Criteria

“Approval Criteria for Initiation of Therapy

• The recipient is 18 years of age or older on the date of the request; AND
• The patient has an established diagnosis of moderate to severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of ≥ 15 on polysomnography (PSG) within the previous 12 months (Documentation is required showing test results with corresponding date); AND
• The prescriber states on the request that the recipient does not have central or mixed sleep apnea; AND
• ONE of the following is true and stated on the request:
   o The requested medication is prescribed concurrently with positive airway pressure (PAP) therapy, unless contraindicated or clinically significant adverse effects are experienced; OR
   o The recipient has a history of non-adherence to PAP therapy; AND
• The recipient has a documented BMI ≥ 30 kg/m² (Date and results of the most recent BMI calculation are stated on the request); AND
• The recipient does not have type 1 or type 2 diabetes; AND
• The prescriber states on the request that the recipient will not use this medication with other tirzepatide products or with any other GLP-1 receptor agonists; AND
• The prescriber states on the request that tirzepatide treatment will be used as adjunct treatment to standard of care therapy, which includes, but is not limited to:
   o Individualized healthy lifestyle counseling; AND
   o Behavioral modification, including a reduced calorie diet and increased physical activity.

Duration of approval for initiation of therapy: 6 months”
Source: LDH Zepbound Clinical Authorization Criteria, Initiation of Therapy (June 2025 / January 2026).

Continuation of Therapy — Verbatim Approval Criteria

“Approval Criteria for Continuation of Therapy

• BOTH of the following is true:
   o The recipient is currently receiving this medication, as evidenced by paid pharmacy claims; AND
   o Documentation provided with the request indicates that the recipient met the initial approval criteria and has received this medication for at least 28 days; AND
• ONE of the following is true and is stated on the request:
   o The recipient lost ≥ 5 percent of baseline body weight OR has continued to maintain their initial 5 percent weight loss and no additional weight gain (Documentation of the recipient's baseline weight prior to initiation of therapy and the recipient's current weight, including the date the weights were taken must be submitted); OR
   o The recipient DID NOT reach the weight loss goal of at least 5 percent and clinical justification for continuation of current therapy is provided; AND
• The prescriber provides supporting documentation of at least 3 months follow up (i.e. clinical visit notes or documentation of updated testing results) that the recipient has achieved or maintained a positive response to treatment from baseline, evidenced by a decrease in AHI and OSA symptoms; AND
• The prescriber states on the request that tirzepatide treatment will be used as adjunct treatment to standard of care therapy, which includes, but is not limited to:
   o Individualized healthy lifestyle counseling; AND
   o Behavioral modification including a reduced calorie diet and increased physical activity; AND
• The request is for a maintenance dose of 10mg or 15mg once weekly (if appropriate based on recipient's current titration schedule).

Duration of approval for continuation / maintenance of therapy: 3–12 months
• For weight loss > 5%, approve for an additional 12 months.
• For weight loss < 5%, approve for 3 months if clinical justification is provided as to why this weight loss goal was not reached (unless previously approved for 3 months – see below).

If previous duration of approval was for 3 months:
• For weight loss > 5%, approve for an additional 12 months.
• For weight loss < 5%, do not approve.”
Source: LDH Zepbound Clinical Authorization Criteria, Continuation of Therapy (June 2025 / January 2026).

The Zepbound continuation bar is distinctly higher than Wegovy’s. In addition to the ≥ 5% weight loss requirement, the prescriber must submit documentation of at least 3 months of follow-up showing a decrease in AHI and improvement in OSA symptoms. This is a dual-endpoint continuation standard unique in the 28-state series — the prescriber must document both metabolic response (weight) and disease-specific response (OSA objective measure). If a patient loses 6% body weight but their AHI has not measurably decreased, the continuation criteria are not met.

The Zepbound criteria references the SURMOUNT-OSA trial (NCT05412004), the FDA pivotal trial supporting the December 2024 Zepbound OSA label expansion. LDH implemented Zepbound OSA coverage 13 months after the FDA label expansion (FDA action December 2024 → LDH policy created June 2025 → implementation January 2026) — at pace with Kentucky (also January 2026) and ahead of Oklahoma (DUR Board March 2026).

GLP-1 T2DM PA criteria (Incretin Mimetics / Enhancers)

Every GLP-1 receptor agonist on the LA Single PDL Incretin Mimetics/Enhancers class (Trulicity, Ozempic, Rybelsus on PDL; Mounjaro, Victoza, Bydureon BCise on NPDL with PA) is gated on the Louisiana Medicaid Diabetes – Hypoglycemics – Incretin Mimetics / Enhancers Clinical Authorization Criteria, verified via direct PDF fetch from ldh.la.gov/assets/medicaid/PharmPC/6_3_25/Diabetes.Hypoglycemics.Incretin.Mimetics.Enhancers.03272025.redline.pdf, 2026-05-10. Revised March 27, 2025; Implementation Date August 2025.

“GLP-1 Agonists

Initial Approval Criteria

• The recipient meets the minimum age requirement (see POS Edits); AND
• The recipient has a diagnosis of type 2 diabetes mellitus; AND
• Documentation is provided confirming a history a hemoglobin A1C (A1C) ≥ 6.5%, with associated date. Note: Established therapy without the above-referenced history of an A1C ≥ 6.5% is not accepted for initial approval; AND
• ONE of the following: (A1C test results and date must be stated on the request)
• The recipient has a hemoglobin A1C (A1C) ≥ 6.5% obtained within the previous 6-month period; OR
• ALL of the following:
• The recipient has an A1C < 6.5% obtained within the previous 6-month period; AND
• The recipient has a history of an A1C ≥ 6.5%; AND
• By submitting the authorization request, the prescriber attests that the requested GLP-1 agent will not be used concurrently with a DPP-4 agent; AND
• If request is for a non-preferred GLP-1 agent – ONE of the following is required:
   o The recipient has had a treatment failure with at least one preferred GLP-1 product; OR
   o The recipient has had an intolerable side effect to at least one preferred GLP-1 product; OR
   o The recipient has documented contraindication(s) to all of the preferred GLP-1 products that are appropriate to use for the condition being treated; OR
   o There is no preferred product that is appropriate to use for the condition being treated.”
Source: LDH Diabetes – Hypoglycemics – Incretin Mimetics / Enhancers Clinical Authorization Criteria, GLP-1 Agonist Initial Approval Criteria (revised March 2025 / August 2025 implementation).

“Subsequent Approval Criteria
Note: Subsequent approval criteria should be used only if the recipient has previously obtained an initial approval using the criteria listed above.

• The prescriber states on the request that the recipient is established on the medication with evidence of a positive response to therapy.”
Source: LDH Incretin Mimetics Clinical Authorization Criteria, Subsequent Approval Criteria (March 2025 / August 2025).

No off-label chronic-weight-management approval is possible through these criteria. A physician cannot submit a PA request for Mounjaro for obesity management under the T2DM GLP-1 criteria; those criteria require a T2DM diagnosis and A1C history. A physician cannot substitute the Zepbound OSA criteria for Mounjaro (Mounjaro is the FDA-labeled tirzepatide brand for T2DM; Zepbound is the FDA-labeled brand for OSA) — they share the same molecule but the criteria are brand-specific. A patient with both T2DM AND OSA cannot use Mounjaro for OSA management even if tirzepatide is the right drug for their comorbidity cluster.

The 5-PBM-per-MCO transition (effective October 1, 2025): the only mid-2025 PBM restructuring in the 28-state series

Louisiana underwent the most significant pharmacy benefit administrative change of any state in the 28-state series in 2025. From May 2019 through September 30, 2025, all Healthy Louisiana MCOs operated under a single-PBM model administered by Prime Therapeutics. Effective October 1, 2025, Louisiana terminated this model and pivoted to a structure in which each MCO contracts with its own PBM for pharmacy claims routing. The transition is documented verbatim in LDH Informational Bulletin 25-27, September 23, 2025, verified via direct PDF fetch from ldh.la.gov/assets/docs/BayouHealth/Informational_Bulletins/2025/IB25-27.pdf.

“Effective October 1, 2025, Louisiana Medicaid is transitioning from a single Pharmacy Benefit Manager (PBM) for all the Medicaid MCOs to each MCO utilizing their own PBM. All six MCOs will have their own BIN, PCN, and Group number.”
Source: LDH Informational Bulletin 25-27, September 23, 2025. ldh.la.gov/assets/docs/BayouHealth/Informational_Bulletins/2025/IB25-27.pdf

The verbatim PBM identity table from IB 25-27:

“Louisiana Medicaid FFS and MCO BIN, PCN, and group numbers for pharmacy claims:

Plan Name                  PBM Name                               BIN        PCN          Group
Fee-for-Service              Gainwell Technologies                     610514    LOUIPROD    n/a
Aetna                          CVS Caremark                             610591    MCAIDADV    RX881J
AmeriHealth Caritas           PerformRx                                  019595    06030000    n/a
Healthy Blue                  Carelon Rx                                  020107     LA           RX8482
Humana Healthy Horizons      Humana Pharmacy Solutions, Inc.      610649    03191502    LAM01
LA Healthcare Connections    Express Scripts                           003858     MA           2ENA
United Healthcare             Optum Rx                                    610494     4041          ACULA”
Source: LDH IB 25-27 PBM Identity Table (September 23, 2025). Note: UnitedHealthcare exited Healthy Louisiana effective December 31, 2025; the five remaining MCOs are the current Healthy Louisiana plans as of January 1, 2026.

Critical operational note: The PBM diversification is operational routing, not policy-decisional. All five MCOs and FFS continue to use the same LDH-published Single PDL and LDH-published Clinical Authorization Criteria for Wegovy, Zepbound, and GLP-1s. A Wegovy initiation PA submitted by a member of Healthy Blue (Carelon Rx) uses the same LDH Wegovy Clinical Authorization Criteria as a PA submitted by a FFS Legacy Medicaid member. The substantive criteria — age, BMI, CVD, T2DM exclusion — are identical across all six payer entities (5 MCOs + FFS). Do not call your MCO’s PBM to inquire about different formulary criteria; there are none.

ULM College of Pharmacy PA Desk: the second state-university FFS PA infrastructure in the series

Louisiana is the second state in the 28-state series (after Oklahoma) with a state-university-administered FFS pharmacy prior authorization infrastructure. The University of Louisiana at Monroe (ULM) College of Pharmacy Prior Approval Desk operates the FFS PA adjudication for Louisiana Legacy Medicaid pharmacy claims.

The ULM PA Desk parallel to Oklahoma’s infrastructure is significant:

• Oklahoma: University of Oklahoma (OU) College of Pharmacy / Pharmacy Management Consultants (PMC) operates the OHCA DUR Board PA recommendations, with DUR Board meeting-approval of each carve-out recommendation. PMC reviews incoming PA requests against the DUR-Board-approved criteria.
• Louisiana: ULM College of Pharmacy Prior Approval Desk administers FFS PA adjudication. The LDH Pharmacy Benefits Management unit defines the Clinical Authorization Criteria; ULM operates the PA intake and review. The policy criteria are LDH-defined; ULM’s role is administrative review, not policy-decisional.

For FFS members (Louisiana Legacy Medicaid, processed by Gainwell Technologies BIN 610514), the PA phone number is 1-866-730-4357 per the PDL Page 1 contact table. Mail submissions go to LDH Bureau of Health Services Financing at 628 N. 4th Street, Baton Rouge, LA 70802. The prescribing practitioner — not the pharmacist or recipient — must submit the PA request per LDH Provider Manual Section 37.5.5.

“The prescribing practitioner is responsible for obtaining prior authorization. Pharmacist or recipient calls/requests will not be accepted.”
Source: LDH Provider Manual Chapter 37, Section 37.5.5 — Who Can Obtain Prior Authorization.

The LDH Provider Manual also specifies turnaround and emergency dispense rules:

“The Prior Authorization process provides for a turn-around response by either telephone or other telecommunications device within twenty-four (24) hours of receipt of a prior authorization request. In emergency situations, providers may dispense at least a seventy-two (72) hour or a three (3) day supply of medication.”
Source: LDH Provider Manual Chapter 37, Section 37.5.5 — Prior Authorization Process Turnaround.

The 5 MCOs and how they defer to the LDH Single PDL

Five Healthy Louisiana MCOs are operational as of January 1, 2026, per LDH press release dated December 12, 2025 (verified via WebFetch of ldh.la.gov/news/7615):

“Aetna Better Health, AmeriHealth Caritas Louisiana, Healthy Blue, Humana, and Louisiana Healthcare Connections.”

“UnitedHealthcare exited Louisiana Medicaid effective December 31, 2025. Current UnitedHealthcare members were reassigned to one of the remaining health plans with a start date of January 1, 2026.”
Source: LDH Press Release (December 12, 2025). ldh.la.gov/news/7615

Here is the consolidated reference table for the five MCOs, their PBMs, PA phone lines, and BIN/PCN/Group routing:

Source: LDH IB 25-27 (September 23, 2025) for BIN/PCN/Group; LDH Single PDL Page 1 (eff. 10/01/2025) for PA phone numbers.

For MCO-specific formulary deferral: AmeriHealth Caritas Louisiana published verbatim on its Pharmacy Benefits page: “Your drug list is the list of medicines the Louisiana Department of Health (LDH) tells AmeriHealth Caritas Louisiana to cover” with reference to the LDH Single PDL (verified via WebFetch of amerihealthcaritasla.com, 2026-05-10). Louisiana Healthcare Connections published a July 1, 2024 newsroom article titled “Medicaid Pharmacy Coverage of Wegovy for Cardiovascular Indications Only” stating: “Coverage is not all-inclusive, as prescription agents used for weight loss still remain a Louisiana Medicaid benefit exclusion” — confirming PDL deferral (verified via WebFetch, 2026-05-10).

SB 433: the active 2026 legislative-expansion push — Senate 31-0, House pending, January 1, 2027 effective date

The editorially distinctive story of Louisiana Medicaid GLP-1 coverage in 2026 is Senate Bill 433. No other state in the 28-state series has an active GLP-1 expansion bill that has cleared an entire chamber with unanimous bipartisan support and has the state Medicaid agency head publicly endorsing it.

SB 433’s legislative action history (verbatim from Louisiana Legislature bill information page legis.la.gov/legis/BillInfo.aspx?s=26RS&b=SB433&sbi=y, verified 2026-05-10):

“MEDICAID: Provides for Medicaid coverage of certain medications. (1/1/27) (RE INCREASE GF EX See Note)”

Sponsor: Senator Gerald Boudreaux (primary)
Co-Authors: Regina Ashford Barrow, Sidney Barthelemy, Royce Duplessis, Samuel Jenkins, Robert ‘Bob’ Owen, Larry Selders

Introduced in Senate (3/30/2026)
Senate Health and Welfare committee reported with amendments (4/15/2026)
Senate Finance committee reported with amendments (4/27/2026)
Passed Senate 31-0 (4/29/2026)
Received in House (5/5/2026)
Referred to House Health and Welfare (5/6/2026)

Effective Date: January 1, 2027
Source: Louisiana Legislature SB 433 (2026 Regular Session) Bill Information Page. legis.la.gov/legis/BillInfo.aspx?s=26RS&b=SB433&sbi=y

What SB 433 would do if enacted (per WAFB April 29, 2026 + Fox8Live May 1, 2026 + Louisiana Illuminator April 16, 2026, verified via WebFetch):

“Senate Bill 433 would allow adults with a body mass index of 35 to 39 to access GLP-1 drugs for obesity if they have another chronic condition, including prediabetes, hypertension or cardiovascular disease.”
Source: WAFB / Fox8Live / Louisiana Illuminator coverage of SB 433 (April 2026).

“Around 145,000 Medicaid enrollees would meet the requirements laid out in the bill.”
Source: WAFB / Fox8Live (April – May 2026).

LDH Secretary Bruce Greenstein has publicly endorsed SB 433. His verbatim quotes:

“Louisiana Health Secretary Bruce Greenstein described GLP-1s as 'a blockbuster drug' and 'an absolute life changer' for many people, and added that the state will apply to participate in Trump’s program to lower GLP-1 costs.”
Source: Louisiana Illuminator, April 16, 2026 (secondary corroboration; direct fetch returned 403; referenced via KALB and Fox8Live secondary reporting).

“'This is one of the few times that I'm very excited about looking at expansion of any Medicaid service.'”
— Bruce Greenstein, LDH Secretary (Fox8Live, May 1, 2026)
Source: Fox8Live, May 1, 2026. Verified via WebFetch.

Sponsor Sen. Boudreaux verbatim:

“'Louisiana's adult obesity rate is about 39%–40%, compared to the national average of about 33% to 34%.'”
— Sen. Gerald Boudreaux (Fox8Live, May 1, 2026)

“'Addressing obesity early provides an opportunity to improve health outcomes while reducing downstream financial burdens.'”
— Sen. Gerald Boudreaux (Fox8Live, May 1, 2026)
Source: Fox8Live, May 1, 2026. Verified via WebFetch.

The cost figures (per KALB April 17, 2026 and Fox8Live May 1, 2026, verified via WebFetch):

“Louisiana's Medicaid director said the annual treatment for one patient costs around $16,000.”

“The expanded coverage could cost as much as $189 million for the first six months of 2027, at least $35 million of which would have to come from the state. During the 2027-28 fiscal year, which starts July 1, 2027, it would cost $296 million, including $55 million in state funding.”

“However, thanks to a new GLP-1 savings program President Donald Trump negotiated, the price tag could end up being far lower for Louisiana, with the state potentially paying as little as $7 million for the first six months of 2027 and $11 million the following fiscal year.”
Source: KALB (April 17, 2026) and Fox8Live (May 1, 2026). Verified via WebFetch.

SB 433 is NOT yet law as of 2026-05-10. The bill passed the Senate 31-0 (April 29, 2026), was received in the House (May 5, 2026), and is pending in the House Health and Welfare Committee (referred May 6, 2026). The Louisiana 2026 Regular Session is scheduled to adjourn June 1, 2026. Whether Governor Jeff Landry will sign or veto SB 433 is not known — his June 2025 veto of the OGB GLP-1 coverage line item in HB 463 creates structural uncertainty. This article will be updated when the bill’s final status is determined.

The OGB distinction is critical: Governor Landry’s June 2025 veto of the state-employee GLP-1 obesity coverage provision in HB 463 (Office of Group Benefits) is NOT a Medicaid event. OGB administers health plans for approximately 212,000 state employees and public school teachers — entirely separate from the 1.5–1.7 million Louisianians in Healthy Louisiana Medicaid. OGB currently covers semaglutide for T2DM only. Do not conflate OGB with Healthy Louisiana.

Appeals: Louisiana Medicaid fair hearings

When a Wegovy or Zepbound PA is denied, the Louisiana Medicaid appeals pathway has three stages. Verified via secondary references to LDH appeals guidance and AmeriHealth Caritas Louisiana appeals page (2026-05-10):

“Members or their representatives can file an appeal within 60 calendar days from the date on the Notice of Action regarding a pharmacy denial or other coverage decision.”

“Results of the appeal resolution are sent to members in a written notice within 30 calendar days of receipt of the appeal.”

“If you disagree with the appeal decision, you have further recourse. You may request a State Fair Hearing within 120 days of the date of the notice of resolution on your appeal. However, you must complete the Medicaid managed care plan's appeals process before you can request a State Fair Hearing.”

“If your appeal concerns a service denial, if you appeal within 10 days of the denial, your current services won't be stopped while your appeal is reviewed.”

“If you want to allow someone to appeal on your behalf, an 'Appeal Representative' form must be sent in with your appeal within 60 calendar days of the date on the adverse-action letter.”
Source: LDH Medicaid appeals guidance (secondary reference to ldh.la.gov/medicaid and AmeriHealth Caritas Louisiana Appeals Page, 2026-05-10).

The three-stage appeal pathway:

1. Step 1 — Internal MCO appeal: File within 60 calendar days of the denial notice. Call your MCO’s PA phone line (table above). The MCO must provide a written decision within 30 calendar days of receiving the appeal. If you appeal within 10 days of the denial, current services continue during review (the “aid-pending” protection).
2. Step 2 — State Fair Hearing: If the MCO appeal is denied, request a State Fair Hearing with the Louisiana Division of Administrative Law (DAL) within 120 days of the MCO appeal decision. You must complete the MCO appeals process before requesting a State Fair Hearing. The DAL administers Medicaid recipient fair hearings under Louisiana administrative law.
3. Authorized representative: An Appeal Representative form submitted within 60 calendar days of the adverse-action letter allows another person (attorney, patient advocate, family member) to appeal on your behalf.

For FFS members, the appeal contact is LDH Bureau of Health Services Financing at 628 N. 4th Street, Baton Rouge, LA 70802, phone 225.342.9500. The Healthy Louisiana Customer Service enrollment broker line is 1.855.229.6848. Louisiana Medicaid Customer Service: 1.888.342.6207.

What an appeal can realistically achieve: If your PA was denied because the prescriber did not submit the Patient Treatment Agreement or did not document the ABI measurement (for Wegovy PAD criterion), an appeal with corrected documentation has a legitimate path to reversal. An appeal cannot override the categorical exclusion — if you do not meet the CV or OSA clinical criteria (e.g., you want Wegovy for chronic weight management without established CVD), a fair hearing cannot grant coverage the LDH criteria do not authorize.

How Louisiana compares: OK, KY, AL, TN closest analogues

Louisiana is Pattern #28 in the 50-state series. It shares structural features with four prior states but is operationally distinctive from all of them.

vs. Oklahoma (Pattern #24) — University PA infrastructure parallel

Oklahoma is the closest analog on two dimensions: (1) Wegovy CV-only + Zepbound OSA-only PA criteria content is substantively similar, and (2) both states use a state-university-administered FFS PA infrastructure (OU College of Pharmacy / PMC in OK; ULM College of Pharmacy in LA). Key differences: OK has Wegovy MASH-only and Imcivree monogenic-obesity carve-outs that LA does not; LA has orlistat on PDL that OK does not; LA has both Wegovy AND Zepbound enumerated on the Single PDL (OK administers via DUR-Board criteria PDFs without a PDL class table); LA is an expansion state (July 1, 2016) while OK expanded later (July 1, 2021). LA’s SB 433 expansion push is directionally opposite to Oklahoma’s stable exclusion posture.

vs. Kentucky (Pattern #21) — Wegovy CV + Zepbound OSA pattern analog

Kentucky is the closest analog at the criteria-content level: Wegovy CV-only (BMI ≥ 27, no T2DM) + Zepbound OSA-only (AHI ≥ 15, BMI ≥ 30, no T2DM). But KY’s drugs are administered via MedImpact PA criteria PDFs only — not enumerated on a Single PDL therapeutic class table. KY also has a Wegovy MASH-only carve-out that LA does not. Most importantly, KY’s 2025–2026 policy movement was in the opposite direction: the Beshear administration proposed expanding chronic-weight-management coverage, the Legislature nullified it via SB 65, and the SB 65 veto override on April 14, 2026 made the exclusion legislatively entrenched until June 1, 2027. Louisiana’s SB 433 is an expansion bill passing with 31-0 momentum — exactly opposite of Kentucky’s 2026 trajectory.

vs. Alabama (Pattern #23) — southern PDL-enumerated carve-out analog

Alabama is the closest southern-state PDL-enumeration analog, but AL enumerates only Zepbound on its PDL (Incretin Mimetics class, OSA-only footnote ^) while Wegovy is off-PDL (Cardiac Agents PA Form 369 only). Louisiana enumerates BOTH Wegovy AND Zepbound on the same Single PDL with Patient Treatment Agreement notation — operationally more transparent than Alabama. Both states exclude T2DM patients from their respective CV/OSA carve-outs. Neither state has general chronic-weight-management coverage. But Louisiana is a Medicaid expansion state (2016) while Alabama is not — the eligible population for any GLP-1 coverage in Louisiana is structurally broader.

vs. Tennessee (Pattern #13) — southern regional comparison

Tennessee TennCare is the most permissive southern Medicaid GLP-1 program in the series, having expanded to broad chronic-weight-management coverage via TennCare rulemaking (Sequence 10-34-25, effective January 26, 2026). Tennessee covers Wegovy, Zepbound, and Saxenda for chronic weight management. Louisiana has not made a parallel rulemaking change. However: Tennessee is a non-expansion state (the 10th-largest non-expansion state Medicaid program by enrollment), while Louisiana expanded in 2016 — giving LA’s coverage universe access to 350,000+ additional low-income adults. If SB 433 is enacted, Louisiana’s BMI 35–39 + comorbidity expansion would partially close the gap with Tennessee’s chronic-weight-management coverage for the highest-risk population subset.

What Louisiana Medicaid patients can do in 2026

If you are a Louisiana Medicaid (Healthy Louisiana) member who wants access to Wegovy, Zepbound, or other GLP-1s, here is what is actionable right now:

If you have established cardiovascular disease and no diabetes

You may qualify for Wegovy under the LDH CV criteria if you are age 45 or older, BMI ≥ 27, and have documented prior MI, prior stroke (ischemic or hemorrhagic), or peripheral arterial disease with ABI < 0.85, prior revascularization, or amputation due to atherosclerotic disease — and you have NOT been diagnosed with T1DM or T2DM. Your prescriber must submit the Louisiana Uniform Prescription Drug Prior Authorization Form along with the completed Semaglutide (Wegovy®) Treatment Agreement for Louisiana Medicaid Recipients. Call your MCO’s PA line (table above) or the FFS line 1-866-730-4357 for submission guidance.

If you have moderate-to-severe obstructive sleep apnea and no diabetes

You may qualify for Zepbound under the LDH OSA criteria if you have an AHI of ≥ 15 on a polysomnography sleep study within the past 12 months, BMI ≥ 30, and no T1DM or T2DM. Your prescriber must document that you are using PAP therapy (CPAP or BiPAP) concurrently — or that you have a history of non-adherence to PAP therapy. The Tirzepatide (Zepbound®) Treatment Agreement must be submitted with the initiation PA request. Continuation requires documentation of ≥ 5% weight loss AND a decrease in AHI after at least 3 months of follow-up.

If you have type 2 diabetes

You cannot access Wegovy for CV risk reduction or Zepbound for OSA under the LDH PA criteria — both explicitly exclude T2DM patients. You may access GLP-1 receptor agonists (Ozempic, Trulicity on PDL as preferred; Mounjaro, Victoza on NPDL with PA) for T2DM management under the Diabetes Hypoglycemics Incretin Mimetics/Enhancers criteria, which require T2DM diagnosis + history of A1C ≥ 6.5% + no concurrent DPP-4.

If you want chronic weight management coverage without CVD or OSA

Current Louisiana Medicaid does not cover Wegovy, Zepbound, Saxenda, Qsymia, Contrave, or phentermine for chronic weight management without an approved medical indication. Orlistat (Xenical) is available with a prescription and POS edits (Age Limit, Diagnosis Code, Prescription Requirement, Quantity Limit) — it is the only general-obesity drug in Louisiana Medicaid’s toolkit for the adult population.

Watch SB 433

Senate Bill 433, if enacted and signed, would create a new coverage pathway for Louisiana Medicaid adults with BMI 35–39 plus prediabetes, hypertension, or cardiovascular disease — effective January 1, 2027. Monitor the bill’s progress in the House Health and Welfare Committee and the full House floor vote. The Louisiana Legislature 2026 Regular Session is scheduled to adjourn June 1, 2026. The bill is sponsored by Sen. Boudreaux at the request of the American Diabetes Association and is backed by LDH Secretary Greenstein — two significant institutional endorsements.

Sources (primary authority documents — verified)

• LDH Single PDL (eff. Jan 1, 2026; updated 04/01/26). ldh.la.gov/assets/healthyla/pharmacy/pdl.pdf
• LDH Wegovy PA Criteria (April 2024 / July 2024 implementation). ldh.la.gov/assets/medicaid/PharmPC/5.15.24/Wegovy.05072024.pdf
• LDH Zepbound PA Criteria (June 2025 / January 2026 implementation). ldh.la.gov/assets/medicaid/PharmPC/9_26_25/Zepbound.06052025.pdf
• LDH Diabetes – Hypoglycemics – Incretin Mimetics / Enhancers Criteria (March 2025 / August 2025 implementation). ldh.la.gov/assets/medicaid/PharmPC/6_3_25/Diabetes.Hypoglycemics.Incretin.Mimetics.Enhancers.03272025.redline.pdf
• LDH Informational Bulletin 25-27 (PBM Transition, September 23, 2025). ldh.la.gov/assets/docs/BayouHealth/Informational_Bulletins/2025/IB25-27.pdf
• LDH Pharmacy Benefits Management Provider Manual, Chapter 37. lamedicaid.com/provweb1/manuals/pharm_benefits_manual.pdf
• LDH Press Release — MCO Landscape Update (December 12, 2025). ldh.la.gov/news/7615
• LDH PBM Transition Page. ldh.la.gov/medicaid/PBMtransition
• Louisiana Healthcare Connections Wegovy Notice (July 1, 2024). louisianahealthconnect.com/newsroom/medicaid-pharmacy-coverage-of-wegovy––for-cardiovascular-indicat.html
• AmeriHealth Caritas Louisiana Pharmacy Benefits page. amerihealthcaritasla.com/pharmacy/benefits
• SB 433 (2026 Regular Session) Bill Information Page. legis.la.gov/legis/BillInfo.aspx?s=26RS&b=SB433&sbi=y
• WAFB — SB 433 coverage (April 29, 2026). wafb.com/2026/04/29/weight-loss-drugs-covered-by-medicaid-senate-could-decide-soon/
• Fox8Live — SB 433 coverage (May 1, 2026). fox8live.com/2026/05/01/bill-could-expand-medicaid-access-ozempic-wegovy-mounjaro-louisiana/
• KALB — SB 433 cost analysis (April 17, 2026). kalb.com/2026/04/17/faced-with-obesity-stats-louisiana-lawmakers-debate-weight-loss-drug-coverage-medicaid-recipients/
• 42 U.S.C. § 1396r-8(d)(2)(A) — Federal optional exclusion authority. Stable public law.

Frequently asked questions

This article is for informational purposes only and does not constitute legal, medical, or pharmacy advice. Louisiana Medicaid policy can change at any time; always confirm current coverage with your MCO or LDH before making clinical or financial decisions. Last verified 2026-05-10.