Pennsylvania Medicaid GLP-1 Coverage 2026: The Policy Reversal — 34 Months of Coverage Terminated January 1, 2026 (MAB2025112403 + 55 Pa.B. 8828 + 55 Pa. Code § 1121.54)

Pennsylvania Medicaid — formally called Medical Assistance (MA), administered by the Pennsylvania Department of Human Services (DHS) and delivered to roughly 80% of enrollees through the HealthChoices managed-care program — covered GLP-1 receptor agonists for chronic weight management from January 2023 through December 31, 2025. On January 1, 2026, that coverage ended. This makes Pennsylvania the most consequential policy reversal in the 50-state Medicaid GLP-1 series: the only top-seven-enrollment state Medicaid program that had a functioning chronic-weight-management GLP-1 pathway — at full FDA-label thresholds (BMI ≥ 30, or BMI ≥ 27 with comorbidity), covering adolescents at the 95th BMI percentile, listing Saxenda, Wegovy, and Zepbound as covered drugs — and then terminated it. Pennsylvania is the inverse of California in this series: both states anchored major 2026 GLP-1 coverage changes in the same 2025-26 budget cycle; California reinstated Wegovy for a MASH indication in April 2026, while Pennsylvania terminated Wegovy, Zepbound, and Saxenda for chronic weight management in January 2026. The directions were opposite.

TL;DR — what Pennsylvania Medicaid covers in 2026

Effective January 1, 2026, Pennsylvania Medical Assistance does not cover GLP-1 receptor agonists for the treatment of overweight or obesity. The operative primary-source statement is MAB2025112403, page 1 (verbatim):

“NOTE: GLP-1 Receptor Agonists are not covered for the treatment of overweight or obesity. GLP-1 Receptor Agonists are covered for the treatment of diagnoses that are indicated in the U.S. Food and Drug Administration (FDA)-approved package labeling or other medically accepted indications excluding treatment of overweight or obesity. Saxenda (liraglutide) will no longer be covered for any indication.”

Four narrow, PA-gated non-obesity indications remain covered:

• Type 2 diabetes (T2D) — Ozempic, Trulicity, Victoza Preferred; Mounjaro, Wegovy, Zepbound Non-Preferred with step therapy. 12-month approval cycles.
• MACE reduction (Wegovy) — BMI ≥ 27 + prior MI/stroke/PAD + optimized CV pharmacotherapy + specialist consultation. Step therapy: failure of Ozempic max dose required. 6-month approval cycles. No diabetes exclusion (unlike Ohio).
• Noncirrhotic MASH with F2/F3 fibrosis (Wegovy) — hepatologist or gastroenterologist consultation; FIB-4 ≥ 1.3 (under 65) or ≥ 2.0 (65+) plus FibroScan/MRE/SWE/ELF; no significant alcohol use; Rezdiffra step-through if applicable. 6-month approval cycles.
• Moderate-to-severe obstructive sleep apnea at BMI ≥ 35 (Zepbound) — PAP adherence or documented PAP intolerance; step therapy requires failure of Ozempic, Wegovy, AND Mounjaro first. 6-month approval cycles.

Saxenda is excluded for all indications in all populations. There is no obesity-indication pathway for any GLP-1 for any age group under the MA Program as of January 1, 2026. Adolescents under 21 retain a theoretical EPSDT-based challenge pathway; see the EPSDT section below. All fills are limited to one-month supplies.

YMYL boundary: we do not promise approval for any specific patient. PA approval depends on individual clinical documentation, MCO adjudication, and current PDL revision.

Where Pennsylvania fits: the 7-state Medicaid series taxonomy

This is the seventh installment of our verbatim-primary-source 50-state Medicaid GLP-1 series. Pennsylvania introduces the seventh distinct structural pattern: a documented policy reversal in which a state that actively covered GLP-1s for obesity then terminated that coverage. No prior state in the series matches this pattern.

Triple-anchor: how the January 1, 2026 termination is legally established

Pennsylvania's GLP-1 obesity-coverage termination rests on three independent primary-source anchors. All three must be understood together; no single document alone establishes the full legal picture.

Anchor 1 — MAB2025112403 (November 24, 2025, effective January 1, 2026)

The operational primary source is Medical Assistance Bulletin MAB2025112403, signed by Deputy Secretary Sally Kozak on November 24, 2025, effective January 1, 2026. The bulletin's PURPOSE statement is verbatim:

“The purpose of this bulletin is to:
1. Inform providers that effective January 1, 2026, coverage will end for drugs containing a glucagon-like peptide-1 (GLP-1) receptor agonist for the treatment of overweight and obesity for Medical Assistance (MA) beneficiaries.
2. Inform providers that Obesity Treatment Agents that do not contain a GLP-1 listed on the Department of Human Services (Department) Statewide Preferred Drug List (PDL) will remain a compensable service for MA beneficiaries.
3. Inform providers of the addition of the GLP-1 Receptor Agonists therapeutic class to the Statewide PDL.
4. Inform providers that drugs containing a GLP-1 receptor agonist will continue to be covered for conditions other than overweight and obesity with a prior authorization.
5. Issue updated handbook pages that include the requirements for prior authorization and the type of information needed to evaluate the medical necessity of prescriptions for GLP-1 Receptor Agonists submitted for prior authorization.”

The BACKGROUND/DISCUSSION section of the MAB tells the complete policy-reversal narrative in one paragraph (verbatim):

“GLP-1 receptor agonists are used to treat diabetes and have been covered by the MA Program since their introduction to the market in 2005. Recently, drugs containing GLP-1 receptor agonists have been approved by the U.S. Food and Drug Administration (FDA) to treat overweight, obesity, obstructive sleep apnea, noncirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced liver fibrosis and to reduce cardiovascular risk in patients who have had a heart attack or stroke or have peripheral arterial disease.

The MA Program began covering drugs containing a GLP-1 receptor agonist to treat overweight and obesity in January 2023 for MA beneficiaries who meet the prior authorization guidelines. Coverage of drugs for weight loss is an optional benefit for Medicaid programs. See 42 U.S.C. § 1396r-8(d)(2)(A). The MA Program will discontinue coverage for drugs containing a GLP-1 receptor agonists for the treatment of overweight and obesity for MA beneficiaries.

Effective January 1, 2026, drugs containing a GLP-1 receptor agonist will not be covered for the treatment of overweight and obesity. Drugs containing a GLP-1 receptor agonist will continue to be covered for all other medically accepted indications with a prior authorization. Saxenda (liraglutide) will no longer be covered for any indication.”

This single MAB block establishes the three-part timeline that is the article's central narrative arc: GLP-1s for diabetes since 2005; GLP-1s for obesity from January 2023; GLP-1s for obesity terminated January 1, 2026.

Anchor 2 — 55 Pa.B. 8828 / Doc. No. 25-1777 (December 27, 2025)

The formal state-level public notice is Pennsylvania Bulletin Volume 55 Issue 52, signed by Secretary Valerie A. Arkoosh and published December 27, 2025 (filed December 26, 2025, 9:00 a.m.). Verbatim operative text:

“The Department of Human Services (Department) announces the discontinuation of coverage of drugs containing a glucagon-like peptide-1 (GLP-1) receptor agonist for the treatment of overweight and obesity for Medical Assistance (MA) beneficiaries, effective for dates of service on and after January 1, 2026.”

The bulletin's Fiscal Impact section is the strongest budget-rationale documentation in the entire seven-state series (verbatim):

“The fiscal impact for Fiscal Year (FY) 2025-2026 is a savings of $348.333 million in total funds ($112.965 million in State funds) in the capitation appropriation. The fiscal impact in FY 2026-2027 is a savings of $836.000 million in total funds ($266.684 million in State funds) in the capitation appropriation.”

The Fiscal Note at the bottom of the bulletin quantifies recurring savings of $266,684,000 per year in state funds for FY 2026-27 through FY 2030-31.

Anchor 3 — 55 Pa. Code § 1121.54 (amended January 2, 2026, effective January 3, 2026, 56 Pa.B. 16)

The regulatory anchor is 55 Pa. Code § 1121.54, “Noncompensable services and items,” which lists 21 categories of pharmaceutical services for which “Payment will not be made to a pharmacy.” The most relevant paragraph, as amended in January 2026 (verbatim from pacodeandbulletin.gov):

“(16) FDA approved pharmaceutical products whose indicated use is not to treat or manage a medical condition, illness or disorder.”

Read alongside the federal authority at 42 U.S.C. § 1396r-8(d)(2)(A) — which explicitly allows states to exclude “Agents when used for anorexia, weight loss, or weight gain” — paragraph (16) provides the state-regulatory layer of the triple-anchor. The regulation was amended on January 2, 2026 (effective January 3, 2026, 56 Pa.B. 16), coinciding with the January 1, 2026 MAB operational effective date.

Research note for readers: the pacodeandbulletin.gov official text is the authoritative source for § 1121.54. Older mirrors (e.g., Justia) may reflect pre-2026 paragraph numbering. The paragraph-16 text above was read from the official state site on 2026-05-10. Confirm at pacodeandbulletin.gov at any time after the 2026 amendment.

The inverse-California narrative: same budget cycle, opposite directions

The single most editorially distinctive finding in the seven-state series is the Pennsylvania-California mirror. Both states are KFF members of the four-state “eliminated coverage” classification from the October 2025 survey — and both anchored their 2026 GLP-1 coverage changes in the same 2025-26 budget context. But the directions were exactly opposite:

The California narrative is documented in the KFF January 2026 tracker verbatim citation (paraphrased classification): “four states (California, New Hampshire, Pennsylvania, and South Carolina) have eliminated coverage of GLP-1s for obesity treatment.” All four states appeared together in the January 2026 KFF update after the October 2025 survey had found 16 states with coverage.

The editorial significance: California's April 2026 MASH re-add shows that budget pressure alone does not permanently foreclose non-obesity GLP-1 coverage in states that have reversed course. Pennsylvania has retained the same non-obesity MACE, MASH, and OSA pathways that Ohio and California operationalize — so the structural architecture for a potential future GLP-1 obesity coverage re-add exists within PA's own MAB. Pennsylvania has not made any public statement about re-adding obesity coverage. The article predicts no legislative outcome.

The inverse-California framing is also the most patient-consequential finding in the series. Pennsylvania's pre-termination obesity coverage was more generous than California's: PA covered at BMI ≥ 30 or BMI ≥ 27 with comorbidity (FDA label thresholds) with no morbid-obesity gating; California had covered at stricter thresholds. Approximately 70,000 PA Medicaid beneficiaries lost chronic-weight- management GLP-1 coverage on January 1, 2026 (per Spotlight PA citing DHS). California's April 2026 MASH re-add restored coverage for a much smaller clinical population.

The 34-month coverage history: what Pennsylvania had before January 1, 2026

Pennsylvania Medicaid covered GLP-1 receptor agonists for chronic weight management from approximately January 2023 through December 31, 2025 — roughly 34 months. This distinguishes PA from every other state in the series: Texas, Florida, and Illinois never covered weight-management GLP-1s under any pathway; New York covered via a limited MACE/morbid-obesity carve-out that was never the FDA-label-aligned obesity pathway. Ohio's weight-loss coverage was always excluded, with MACE/MASH carve-outs added only in January 2026.

The historical record is anchored in the September 2, 2024 DHS Obesity Treatment Agents Prior Authorization Form (now superseded for all GLP-1 requests). This form, effective as recently as September 2024 — 15 months before the termination — listed verbatim adult criteria:

“1. The beneficiary is 18 years of age or older and:
Pre-treatment weight: ______ Pre-treatment BMI: ______
[ ] Has a BMI greater than or equal to 30 kg/m2
[ ] Has a BMI greater than or equal 27 kg/m2 and less than 30 kg/m2 AND at least one of the following weight-related comorbidities: cardiovascular disease, obstructive sleep apnea, dyslipidemia, prediabetes, hypertension, type 2 diabetes, metabolic syndrome, other (list)”

And verbatim adolescent criteria:

“2. The beneficiary is less than 18 years of age and:
Pre-treatment BMI: ______ Pre-treatment BMI z-score: ______
[ ] Has a BMI in the 95th percentile or greater standardized for age and sex based on current CDC charts”

The form explicitly listed Saxenda, Wegovy, and Zepbound as preferred GLP-1-containing Obesity Treatment Agents. PA's pre-2026 coverage was FDA-label-aligned at both the adult (BMI ≥ 30; BMI ≥ 27 with comorbidity) and adolescent (95th percentile) thresholds — the most generous adult obesity-coverage pathway among the seven states surveyed in this series. The January 1, 2026 termination ended a coverage pathway that was still being used by an estimated 70,000 beneficiaries.

The MAB2025112403 PROCEDURE section adds one more patient-impact note (verbatim):

“Current prior authorizations for drugs containing a GLP-1 receptor agonist will no longer be valid after December 31, 2025, regardless of the condition being treated. Prescribers will need to submit new requests for prior authorization for all beneficiaries receiving a drug containing a GLP-1 receptor agonist effective January 1, 2026.”

This PA invalidation applied to all GLP-1 PAs — even T2D, MACE, and MASH — requiring every PA to be re-submitted in advance of the January 1, 2026 effective date, creating a real operational disruption for patients on covered indications.

Fiscal motivation: $223M → $650M → $1.3B → $836M/year savings

The 55 Pa.B. 8828 Fiscal Impact section provides the most quantified budget-rationale documentation of any state in the series. Spotlight PA (December 2025) reported the trajectory DHS presented in support of the termination:

• 2022 PA Medicaid GLP-1 spending (T2D only, pre-obesity coverage): $223.3 million
• 2024 PA Medicaid GLP-1 spending (T2D + obesity coverage): $650 million
• 2025 PA Medicaid GLP-1 spending (T2D + obesity, projected full year): on track to exceed $1.3 billion
• FY 2025-26 savings from termination: $348.333 million total funds / $112.965 million state funds
• FY 2026-27 and every subsequent year: $836 million in total funds / $266.684 million in state funds

At approximately 70,000 affected beneficiaries and $836 million in annual full-year savings, PA Medicaid was spending roughly $11,940 per beneficiary per year on GLP-1 obesity treatment — consistent with a typical Wegovy 2.4 mg or Zepbound 15 mg WAC of approximately $1,000/month before Medicaid net pricing.

The political framing from the legislature (Spotlight PA verbatim quotes):

Senate Majority Leader Joe Pittman (R., Indiana): “Looking for ways to save taxpayers money while continuing to provide core government services was a critical part of the final budget agreement.”

Senate Minority Leader Jay Costa (D., Allegheny): “Our caucus will be keeping a close eye on the impact of these decisions as we move forward, and we will continue our fight to ensure every Pennsylvanian gets the care and medication they need.”

DHS Secretary Val Arkoosh (paraphrased by Spotlight PA) wanted to ensure the drugs “are used appropriately by those who need it most.” The budget rationale is the documented policy motivation. This article does not editorially endorse the termination.

Wegovy MACE pathway — FDA-label-aligned, no diabetes exclusion (most patient-favorable in the cluster)

PA's MACE reduction pathway for Wegovy is the most patient- favorable version in the seven-state series. The verbatim initial-PA criteria from MAB2025112403 (pages 2-3):

“ii. For the reduction in risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke), all of the following:
a) Is prescribed the GLP-1 Receptor Agonist by or in consultation with an appropriate specialist (e.g., cardiologist, vascular surgeon, neurologist),
b) A recent body mass index (BMI) greater than or equal to 27 kg/m2,
c) One of the following:
(i) Prior myocardial infarction,
(ii) Prior stroke,
(iii) Peripheral arterial disease and at least one of the following: a. Intermittent claudication with ankle-brachial index less than 0.85 (at rest), b. A history of peripheral arterial revascularization procedure, c. A history of amputation due to atherosclerotic disease,
d) The requested drug will be used in combination with optimized pharmacotherapy for established cardiovascular disease based on current consensus guidelines unless contraindicated or not tolerated”

Three features distinguish PA's MACE criteria from the other six states:

• No diabetes exclusion. Ohio's January 7, 2026 P&T-approved criteria explicitly state “Wegovy will not be authorized for patients with type 1 or type 2 diabetes.” PA's criteria contain no such exclusion. A patient with established CVD, BMI ≥ 27, and type 2 diabetes is eligible for Wegovy under the PA MACE pathway as long as the prescriber documents optimized CV pharmacotherapy. This is directly aligned with the FDA Wegovy SELECT-trial-supported MACE label, which has no diabetes exclusion.
• BMI threshold aligns with the FDA label (BMI ≥ 27). New York's NYRx Wegovy DUR pathway requires BMI ≥ 40 — stricter than the FDA label. PA and Ohio both use ≥ 27. PA's version is patient-favorable because it does not add the T2D exclusion Ohio uses.
• No lifetime treatment-attempt cap. NY caps Wegovy MACE at two treatment attempts per lifetime. PA has no such cap: renewals are approved in 6-month cycles as long as renewal criteria are met.

Step therapy applies: non-preferred Wegovy for the MACE indication requires a history of therapeutic failure of the maximum FDA-approved dose of Ozempic (semaglutide).

Wegovy MASH pathway — broader biomarker panel than Ohio, including ELF score

PA's noncirrhotic MASH pathway for Wegovy includes a broader biomarker confirmation panel than Ohio's January 2026 criteria. The verbatim initial-PA criteria from MAB2025112403 (page 3):

“iii. For the treatment of noncirrhotic metabolic dysfunction- associated steatohepatitis (MASH), all of the following:
a) Is prescribed the GLP-1 Receptor Agonist by or in consultation with a hepatologist or gastroenterologist,
b) Has a diagnosis of MASH with moderate to advanced liver fibrosis (consistent with stage F2 or F3 fibrosis) as confirmed by one of the following:
(i) Liver biopsy within the past three years
(ii) A recent FIB-4 index greater than or equal to 1.3 for beneficiaries less than 65 years of age (or greater than or equal to 2.0 for beneficiaries greater than or equal to 65 years of age) and one of the following:
a. Liver stiffness measurement by vibration controlled transient elastography (VCTE) (e.g., Fibroscan),
b. Magnetic resonance elastography (MRE),
c. Shear wave elastography (SWE),
d. Enhanced Liver Fibrosis (ELF) score,
c) Does not have significant alcohol use (defined as alcohol consumption of more than one drink per day for natal females or more than two drinks per day for natal males) or alcohol dependence,
d) The requested drug will be used in combination with optimized pharmacotherapy for established comorbid diseases (e.g., cardiovascular disease, dyslipidemia, diabetes, hypertension) based on current consensus guidelines unless contraindicated or not tolerated,
e) If currently taking Rezdiffra (resmetirom) with a plan to add concomitant therapy with a GLP-1 Receptor Agonist, failed to show improvement in liver fibrosis after a trial of Rezdiffra (resmetirom) for greater than or equal to 12 months”

The PA MASH criteria contain four features not present in Ohio's January 2026 P&T-approved criteria:

• ELF score as a biomarker option. Ohio's MASH criteria accept FIB-4 plus MRE, MAST, or FibroScan LSM. PA also accepts the Enhanced Liver Fibrosis (ELF) score, which Ohio does not reference. The ELF score is particularly useful for patients who cannot undergo MRE.
• Age-stratified FIB-4 thresholds. PA uses FIB-4 ≥ 1.3 for patients under 65 and FIB-4 ≥ 2.0 for patients 65 and older. The higher threshold for older adults reflects the well-documented age-related FIB-4 false-positive issue and is consistent with AASLD 2023 NAFLD guidance. Ohio's criteria do not include this age stratification.
• Specific alcohol-use exclusion clause. PA defines “significant alcohol use” as “more than one drink per day for natal females or more than two drinks per day for natal males.” Ohio's verified January 7, 2026 minutes do not include this clause.
• Rezdiffra (resmetirom) sequencing rule. PA requires patients currently on Rezdiffra to demonstrate at least 12 months of treatment failure before adding a concomitant GLP-1. This is a thoughtful clinical sequencing constraint that prevents simultaneous initiation of two MASH-specific therapies. No other state in the series has an equivalent rule.

Zepbound OSA pathway — structural step-therapy barrier even within the carve-out

PA's coverage of Zepbound for moderate-to-severe OSA is the most operationally complex pathway in the seven-state series. The verbatim initial-PA criteria from MAB2025112403 (page 2):

“i. For the treatment of moderate to severe obstructive sleep apnea (OSA), all of the following:
a) A recent body mass index (BMI) greater than or equal to 35 kg/m2,
b) A diagnosis of moderate to severe OSA confirmed within the last two years according to one of the following:
(i) The most recent consensus treatment guidelines (e.g., American Academy of Sleep Medicine International Classification of Sleep Disorders)
(ii) A baseline apnea-hypopnea index greater than or equal to 15 events per hour,
c) At least one of the following clinical symptoms:
(i) Excessive daytime sleepiness (e.g., Epworth Sleepiness Scale [ESS ≥10])
(ii) Reduced-sleep related quality of life (e.g., snoring, nocturnal choking insomnia, disruption of partner's sleep, morning headaches, nocturia, etc.),
d) One of the following:
(i) Utilization of positive airway pressure (PAP) with documented adherence to PAP treatment (defined as use of a PAP device for greater than or equal to four hours per night on 70% of nights during a consecutive 30-day period)
(ii) Both of the following: a. If intolerant to PAP, must submit chart documentation that trouble shooting strategies have been tried to address barriers (e.g., provider consultation for mask-related issues, increasing humidity settings, addressing claustrophobia concerns) b. If the beneficiary has a medical reason PAP cannot be used or is still intolerant to PAP despite troubleshooting strategies, utilization of or intolerance to an oral appliance for OSA”

The OSA pathway is FDA-label-aligned (BMI ≥ 35, moderate-to-severe OSA, documented PAP engagement) — but the non-preferred step therapy creates a structural access barrier. The verbatim step-therapy requirement from MAB2025112403 (pages 4-5) for non-preferred GLP-1s for non-diabetes diagnoses:

“iii. For Zepbound (tirzepatide), a history of therapeutic failure* of or a contraindication or an intolerance^ to the maximum FDA-approved doses of Ozempic (semaglutide), Wegovy (semaglutide), and Mounjaro (tirzepatide) that would not be expected to occur with the requested drug”

Zepbound is the only FDA-approved drug for the OSA indication. Yet PA's step-therapy ladder requires documented failure of Ozempic, then Wegovy, then Mounjaro — all of which are off-label for OSA — before Zepbound can be authorized. A patient with moderate-to- severe OSA at BMI ≥ 35 with documented PAP intolerance who has never tried a GLP-1 cannot start at the FDA-approved indication drug; they must first trial and fail three other agents. This is a structural barrier to FDA-label-aligned care within the OSA carve-out itself.

OSA renewal additionally requires (verbatim from MAB page 9):

“If initial dose titration has been completed and the beneficiary has been using the GLP-1 Receptor Agonist for at least three consecutive months at the maximum tolerated dose, has 5% total body weight loss and documentation of dietary changes”

Saxenda total exclusion + EPSDT tension

Pennsylvania's Saxenda exclusion is the most sweeping single-drug exclusion in the seven-state series. The MAB2025112403 is unambiguous (verbatim, repeated in both the initial-PA and renewal-PA sections):

“Saxenda (liraglutide) will no longer be covered for any indication.”

This is a total exclusion, not an indication-specific exclusion. Saxenda is excluded even for:

• Off-label T2D management (the liraglutide 1.8 mg T2D dose is covered as Victoza; Saxenda's 3 mg dose is specifically excluded)
• Adolescent obesity — the FDA-approved adolescent indication (Saxenda received FDA approval for chronic weight management in adolescents 12 years and older in December 2020)
• Any other FDA-approved or medically-accepted indication

The EPSDT tension arises here. Federal Medicaid law — Title XIX of the Social Security Act, 42 U.S.C. § 1396a(a)(43) and § 1396d(r) — requires state Medicaid programs to cover all medically necessary treatments for individuals under 21 (the Early and Periodic Screening, Diagnostic, and Treatment mandate). Saxenda carries an FDA-approved adolescent obesity indication (ages 12 and older, BMI ≥ 95th percentile). PA's blanket “Saxenda will no longer be covered for any indication” may collide with EPSDT requirements for under-21 MA recipients for whom Saxenda is the prescribed FDA-labeled treatment.

The Pennsylvania Health Law Project (PHLP) states (verbatim):

“Medicaid plans cannot deny GLP-1 coverage for someone under age 21 simply because it is prescribed for obesity/overweight.”

PHLP's interpretation is that EPSDT overrides the optional-benefit exclusion for GLP-1s generally for individuals under 21. The Saxenda exclusion goes further: it eliminates Saxenda entirely, even for the adolescent population for which it has FDA label approval. We do not opine on the legal resolution of this EPSDT tension. Adolescents under 21 who are denied Saxenda (or any other GLP-1 for obesity) should pursue the BHA appeal pathway citing EPSDT with assistance from PHLP (1-800-274-3258). Wegovy has FDA approval for adolescents 12 and older (December 2022) and is not subject to the total-exclusion language; it remains available with PA for MACE, MASH, and other non-obesity FDA indications.

One-month fill limit + adherence-burden risk

MAB2025112403 establishes a fill-limit restriction (verbatim, page 12):

“Prescriptions for GLP-1 Receptor Agonists will be limited to a one-month supply per fill.

Requests for prior authorization of GLP-1 Receptor Agonists will be approved as follows:
1. For a GLP-1 Receptor Agonist for a diagnosis of diabetes, requests will be approved for up to 12 months.
2. For a GLP-1 Receptor Agonist for a diagnosis of OSA, requests will be approved for up to six months unless otherwise specified in Section B.
3. For GLP-1 Receptor Agonists for all indications other than diabetes or OSA (excluding treatment of overweight or obesity), requests will be approved for up to six months.”

The one-month fill limit means every patient on Wegovy for MACE reduction must obtain 12 monthly refills per year — compared to a typical 90-day supply available under commercial plans. Each refill requires pharmacy dispensing, which creates a gap risk. Per FDA Section 2 dosing guidance for Wegovy (DailyMed SetID ee06186f), a missed dose more than five days late requires the patient to resume at the next scheduled dose; if the gap is long enough to require re-titration, the patient faces additional clinical burden and cost. The one-month limit is not a coverage-eligibility issue, but it is a real adherence-burden risk that providers managing PA MACE patients should account for in care coordination.

YMYL trap: Non-Preferred PDL listing is NOT obesity coverage

The January 2026 v8 PA DHS Statewide PDL lists Wegovy, Zepbound, and Mounjaro as “Non-Preferred” in the GLP-1 Receptor Agonists therapeutic class. This PDL listing is the most common source of patient and provider confusion about PA Medicaid's current GLP-1 coverage stance.

The Non-Preferred PDL listing does NOT establish that Wegovy or Zepbound are covered for chronic weight management. The PDL is a per-drug formulary classification document; it lists which drugs require prior authorization and at what tier. The MAB2025112403 is the operative indication-restriction document. The Non-Preferred listing means those drugs are available with prior authorization for FDA-approved indications that PA still covers: MACE, MASH, OSA, T2D (for the T2D- indicated products), and other non-obesity FDA-approved or medically- accepted indications. A prescriber who submits a PA for Wegovy for chronic weight management — even citing Non-Preferred status and step therapy — will be denied, because the MAB excludes the obesity indication entirely.

This is an exact parallel to the Illinois Meridian/YouthCare YMYL trap documented in the Illinois article: in that case, Meridian Illinois's PDL Update notices listed Wegovy and Zepbound by name under utilization-management restrictions. Those were quantity-limit edits for the T2D-indication class, not coverage authorizations for the weight-management indication. The PA situation is structurally identical: the drug appears on the PDL in a non-obesity therapeutic context, but the MAB is what governs indication-level coverage.

The PDL header itself acknowledges this dynamic (verbatim, page 1):

“The Statewide PDL is not an all-inclusive list of drugs covered by Medical Assistance. Drugs in Statewide PDL classes that are new to market will be non-preferred until reviewed by the DHS Pharmacy and Therapeutics Committee.”

And verbatim from the PDL legend (page 1):

“Non-preferred agents require prior authorization”

That prior-authorization requirement governs the drug's coverage for eligible indications. The MAB2025112403 removes overweight/obesity from the eligible-indication list entirely. Prior authorization cannot be granted for an excluded indication.

The January 2026 v8 Statewide PDL — verbatim listings

For completeness, the verbatim PDL listings (verified from penn-statewide-pdl-012026-v8.pdf, lines 1755-1763 and 2696-2708):

GLP-1 RECEPTOR AGONISTS therapeutic class (page 27 of the PDL):

• Preferred: Ozempic (semaglutide) Pen — PA, QL
• Preferred: Rybelsus (R1 formulation) (semaglutide) 3 mg, 7 mg, 14 mg Tablet — PA, QL
• Preferred: Trulicity (dulaglutide) Pen — PA, QL
• Preferred: Victoza (liraglutide) Pen — PA, QL
• Non-Preferred: Exenatide Pen — QL
• Non-Preferred: Liraglutide 2-Pak, 3-Pak Pen (generic Victoza) — QL
• Non-Preferred: Mounjaro (tirzepatide) Pen — QL
• Non-Preferred: Wegovy (semaglutide) Pen — QL
• Non-Preferred: Zepbound (tirzepatide) Pen — QL

OBESITY TREATMENT AGENTS class (page 41 of the PDL) — January 2026 v8 contains NO GLP-1 receptor agonist:

• Preferred: Phentermine Capsule — QL
• Preferred: Phentermine Tablet — QL
• Non-Preferred: Benzphetamine, Diethylpropion, Diethylpropion ER, Evekeo (amphetamine), Lomaira (phentermine), Orlistat, Phendimetrazine, Phendimetrazine ER, Phentermine- Topiramate ER, Xenical (orlistat)

PA Medicaid still covers phentermine and orlistat for adult chronic weight management. The Obesity Treatment Agents class is now functionally a phentermine/orlistat-only category — the legacy non-GLP-1 anti-obesity drug shelf. The MAB2025112403 explicitly preserves this (verbatim, page 2):

“Obesity Treatment Agents that do not contain a GLP-1 receptor agonist will continue to be covered by the MA Program. Drugs that are designated as preferred in the Obesity Treatment Agents Statewide PDL therapeutic class will be available without prior authorization (e.g., phentermine capsule, phentermine tablet) as long as quantity limits/daily dose limits are not exceeded.”

Absent from the January 2026 v8 PDL entirely: Saxenda (liraglutide 3 mg), Foundayo (LillyDirect tirzepatide cash-pay brand — not a Medicaid pathway regardless). Bydureon BCise (extended- release exenatide) is not individually listed; only “Exenatide Pen” appears, which the article does not individually verify as covering the Bydureon BCise weekly formulation.

OptumRx + PROMISe™ — PA's PBM structure vs Ohio and Illinois

Pennsylvania's PBM structure is unlike any other state in the series. The PA DHS Pharmacy and Therapeutics Committee web page states (verbatim):

“OptumRx, Inc provides clinical and financial analysis support to the P&T Committee.”

OptumRx serves as the FFS PBM clinical/financial analysis contractor, analogous to Acentra in Texas, UIC College of Pharmacy in Illinois, Magellan in California, and Gainwell in Ohio. The key structural difference:

• Ohio Gainwell SPBM: a Single PBM that consolidates all managed-care and FFS pharmacy adjudication into one statewide system. No plan-level divergence is structurally possible across CareSource, Buckeye, AmeriHealth Caritas, Molina, Anthem, Humana.
• Pennsylvania PROMISe™ + OptumRx: DHS retained an independent FFS claims processor (PROMISe™) and contracted OptumRx for PBM clinical/financial analysis. The HealthChoices MCOs each contract their own PBMs separately (UPMC Health Plan with UPMC's internal PBM; Highmark Wholecare with Express Scripts; AmeriHealth Caritas Pennsylvania with PerformRx transitioning to OptumRx in 2027). However, the Statewide PDL's PA criteria override MCO PBM decisions for any drug class on the PDL. The GLP-1 RA class IS on the Statewide PDL, so the PA criteria from MAB2025112403 bind all MCOs.

The operative PDL footnote (verbatim, page 1) confirms this:

“Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs.”

The practical implication: while plan-level variation is structurally possible for drug classes not on the Statewide PDL, the GLP-1 RA class's Statewide PDL inclusion means every HealthChoices MCO — UPMC for You, Geisinger Health Plan, Highmark Wholecare, Aetna Better Health PA, AmeriHealth Caritas PA, Health Partners Plans, and PA Health & Wellness — applies the same MAB2025112403 criteria and the same obesity-indication exclusion.

The one verified MCO deferral statement is from Health Partners Plans (verbatim from their GLP-1 coverage page):

“Effective January 1, 2026, GLP-1 drugs for the treatment of overweight or obesity will no longer be covered unless your doctor submits a new prior authorization request.”
“Previously approved requests for GLP-1 drugs will end on December 31, 2025. You will not be able to refill your prescription without a new authorization.”

UPMC for You, Highmark Wholecare, AmeriHealth Caritas PA, Aetna Better Health PA, Geisinger Health Plan, and PA Health & Wellness individual MCO-formulary pages were not independently verified in this article's research session. The Statewide PDL binding mechanism applies; readers should confirm with their specific MCO member-services line.

HB 1470 — the subscription-model legislation (procedurally dormant)

House Bill 1470 of the 2025-2026 Regular Session (sponsors: Rep. Arvind Venkat, D-30, Allegheny County; co-sponsor Rep. Bryan Cutler, R-100, Lancaster County) would direct DHS to seek a federal CMS waiver for a “subscription model” for GLP-1 agonists. The bill's short title (verbatim from palegis.us): “An Act amending the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, in public assistance, providing for subscription model for GLP-1 agonists.”

Last action: May 15, 2025 — Referred to House Human Services Committee. As of 2026-05-10, no further action has been taken — roughly 12 months of inactivity. The bill would model Louisiana's and Washington's Hepatitis C subscription waivers as structural analogues (those waivers reduced LA Medicaid Hep C spending from a potential $760M/year to $35M/year).

Rep. Venkat (Spotlight PA verbatim): “We say that we want to prevent severe illness. And unfortunately this is an example where we are restricting access in a way that will likely lead to more severe illness and less health and well-being among our fellow Pennsylvanians.”

This article does not predict legislative outcomes. “Pending in House Human Services Committee since May 15, 2025” is the strongest verifiable claim.

Note: Two other 2025-2026 PA bills sometimes referenced in GLP-1 media coverage — SB 770 and HB 1209 — address firearms and cyber charter school staffing, respectively. Neither has any connection to GLP-1 medications or Medicaid pharmacy coverage. The authoritative GLP-1 legislation is HB 1470.

T2D vs weight-loss coverage — the most common confusion point

The most frequent patient and provider error when reading about PA Medicaid GLP-1 coverage is conflating T2D coverage with weight-loss coverage. The Statewide PDL lists Ozempic, Trulicity, and Victoza asPreferred — meaning patients with T2D can access these drugs with prior authorization and standard step therapy. This creates the impression that “GLP-1s are covered.” They are — for T2D.

The MAB2025112403 initial-PA criteria for T2D (verbatim, pages 1-2):

“1. For the treatment of diabetes, one of the following:
a. For a preferred GLP-1 Receptor Agonist for the treatment of diabetes, at least one of the following:
i. A diagnosis of diabetes
ii. A history of an antidiabetic drug (excluding metformin, SGLT-2 inhibitors, and drugs containing a GLP-1 receptor agonist) within the last 120 days
b. For a non-preferred GLP-1 Receptor Agonist for the treatment of diabetes, all of the following:
i. A diagnosis of diabetes,
ii. A history of therapeutic failure of or a contraindication or an intolerance to the maximum FDA-approved dose of the preferred GLP-1 Receptor Agonists approved or medically accepted for the beneficiary's diagnosis,
iii. The prescribed GLP-1 Receptor Agonist is approved by the FDA for the treatment of diabetes”

The T2D PA criteria require a diabetes diagnosis (or 120-day antidiabetic drug history). A patient whose provider attempts to submit Ozempic for weight loss as a T2D PA — even if the patient has prediabetes — will be denied. The MAB's catch-all clause (section iv) explicitly excludes “treatment of overweight or obesity” from every non-T2D non-MACE non-MASH non-OSA pathway.

Excluded populations and program scope

This article covers PA Medical Assistance (Medicaid) fee-for-service and HealthChoices managed care only. The following populations and programs are out of scope:

• Dual-eligible beneficiaries (Medicare + Medicaid): Approximately 400,000 PA Medicaid beneficiaries also have Medicare Part D for prescription drugs. Their GLP-1 coverage is governed by Medicare Part D rules, not PA Medicaid rules. Medicare Part D historically excluded weight-loss agents, but Wegovy received Medicare Part D coverage for the MACE indication in 2024 and for MASH in August 2025. Dual-eligible coverage specifics were not individually verified for this article; readers should consult their Medicare Part D plan.
• CHIP (Children's Health Insurance Program / CHIP): Pennsylvania's CHIP program has different formulary rules than Medicaid. CHIP coverage is not addressed in MAB2025112403 or the Statewide PDL.
• Pennie marketplace plans: Pennsylvania operates its own ACA insurance marketplace (Pennie). Commercial and marketplace plans have separate formulary rules governed by the ACA, not Pennsylvania Medicaid law. Pennie plan formularies are not covered in this article.
• Community HealthChoices (CHC): Pennsylvania's managed long-term services and supports program for adults who are dual-eligible or need LTSS. CHC pharmacy benefits follow Medicaid pharmacy rules for non-Medicare-covered drugs, but the specific application to GLP-1s for CHC-enrolled dual-eligibles is not individually verified.

7-state comparison — MACE pathway across the cluster

PA's position on the key clinical parameters across the series:

Patient action steps

If you are a Pennsylvania Medical Assistance member in 2026:

1. GLP-1 for weight loss denied? The denial is a coverage determination, not a PA adjudication error. A fair hearing to reverse a policy-level weight-management denial is unlikely to succeed unless you are under 21 and citing EPSDT. Contact PHLP at 1-800-274-3258 for free legal aid before filing.
2. Established cardiovascular disease (prior MI/stroke/PAD) + BMI ≥ 27? Ask your cardiologist, vascular surgeon, or neurologist to submit a Wegovy PA under the MACE indication using MAB2025112403 section ii criteria. The T2D exclusion that applies in Ohio does NOT apply in PA.
3. Documented MASH with F2/F3 fibrosis? Ask a hepatologist or gastroenterologist to submit Wegovy under the MASH pathway. Ensure FIB-4 age-stratification (use the ≥ 2.0 threshold if patient is 65 or older) and ELF score documentation if biopsy is not available.
4. Severe OSA at BMI ≥ 35 + documented PAP adherence? Zepbound is available with PA, but the step-therapy barrier (Ozempic → Wegovy → Mounjaro failures first) creates a real access challenge. Consider whether a prescriber can document step- therapy failures or contraindications for the three preceding agents.
5. T2D? Ozempic, Trulicity, and Victoza remain Preferred on the Statewide PDL for T2D. Mounjaro and Wegovy are Non-Preferred for T2D and require step therapy through the Preferred agents first.
6. Under 21 and denied a GLP-1 for obesity? Contact PHLP (1-800-274-3258) immediately. Federal EPSDT may provide a pathway. Saxenda EPSDT tension is unresolved; Wegovy (which has adolescent label approval, December 2022) is not subject to the total- exclusion language.
7. Cash-pay bridge during appeal: NovoCare Wegovy $299/month; LillyDirect Zepbound vials $299-$449/month; Foundayo (oral orforglipron) $149/month at LillyDirect.

Appeal pathway — Bureau of Hearings and Appeals (BHA)

Pennsylvania Medical Assistance appeals are heard by the Bureau of Hearings and Appeals (BHA), which the DHS web page describes (verbatim):

“BHA conducts the fair hearings and decides the DHS applicant and recipient appeals and the appeals from Department of Aging adverse actions. The bureau currently receives approximately 100,000 appeals per year.”
“BHA reviews appeals on various benefits programs managed by the Departments, such as Medical Assistance (Medicaid), Supplemental Nutrition Assistance Program (SNAP), Cash Assistance, and Subsidized Child Care. Additionally, BHA also reviews actions by the various Health Maintenance Organizations (HMOs) and Managed Care Organizations (MCOs) that manage the benefits provided under the MA program.”

The appeal timeline is governed by 55 Pa. Code § 275.4 (verbatim):

“Appeals shall be filed within 30 days from the date of the written notice... If the appeal is filed within 15 days of the mailing date of the notice, public assistance benefits will be continued at the previously authorized amount until a decision is rendered.”

Practical timeline:

• Day 1-15 from denial notice: File appeal AND request “aid pending appeal” — continued coverage while the appeal is pending (only available within this window).
• Day 16-30: File appeal but lose aid-pending-appeal. No continued coverage during pendency.
• Day 30+: Appeal rights forfeit.
• For HealthChoices MCO denials: exhaust the MCO's internal grievance process first (typically 30-day timeline per PHLP). Only after the MCO internal appeal is exhausted can the recipient request a BHA fair hearing.
• BHA hearing: conducted by an Administrative Law Judge, typically by telephone, typically 60-90 days from filing.
• BHA decision: typically issued within 90 days of the hearing.

Realistic scope of appeal success: a fair hearing can correct adjudication errors (misread diagnosis codes, incorrect step- therapy logic, missing specialist documentation not reviewed). It cannot override a policy-level coverage determination. A weight-management- indication appeal under MAB2025112403 is a policy-level determination and is unlikely to succeed without an EPSDT argument (under-21) or an alternative indication (MACE, MASH, OSA). PHLP (1-800-274-3258) and Community Legal Services of Philadelphia (for Philadelphia County) are free legal-aid resources.

Related research in this series

• California Medi-Cal GLP-1 coverage (2026): the reversal that removed Wegovy + Zepbound for weight loss — the inverse-California companion article. Both PA and CA anchored their 2026 GLP-1 coverage changes in the same 2025-26 budget context and appear together in KFF's four-state “eliminated coverage” classification. California reinstated Wegovy for MASH in April 2026; Pennsylvania terminated Wegovy/Zepbound/Saxenda for obesity in January 2026. Same calendar window, opposite directions.
• Ohio Medicaid GLP-1 coverage (2026): triple-anchored exclusion + the January 2026 Wegovy MACE/MASH carve-back-in — the closest structural twin for PA's MACE and MASH carve-out architecture. Both states cover Wegovy for MACE (BMI ≥ 27) and MASH (F2/F3 fibrosis). Key PA vs OH differences: PA's MACE pathway does NOT exclude T2D patients (Ohio explicitly does); PA's MASH biomarker panel is broader (ELF score + age-stratified FIB-4; Ohio doesn't include ELF); PA adds Zepbound for OSA (Ohio has no OSA pathway as of January 2026).
• Illinois Medicaid GLP-1 coverage (2026): the strictest exclusion in the series — doubly-anchored, no MACE/MASH/OSA pathway — the YMYL-trap companion. Illinois is the only other state in the cluster with a documented YMYL trap on Non-Preferred PDL listings (Meridian/YouthCare listing Wegovy in utilization-management edits, not coverage authorizations). Illinois has no Wegovy MACE, MASH, or OSA pathway — making it strictly more restrictive than PA on non-obesity indications.
• New York Medicaid (NYRx) GLP-1 coverage and Wegovy MACE pathway (2026) — structural comparison for the MACE pathway. NY MACE BMI threshold = 40 (stricter than FDA label and PA/OH); NY has a 2-attempt lifetime cap (PA has none); NY does not exclude T2D patients from MACE (neither does PA); NY has no MASH pathway and no OSA pathway.
• GLP-1 insurance dropped coverage appeal playbook — the four-phase appeal logic and cash-pay bridge strategies. Pennsylvania is the prime policy-reversal case study in this playbook: the only state in the series where patients were actively receiving GLP-1s under a covered obesity pathway and then lost that coverage due to a deliberate state policy change — not a commercial formulary swap.
• GLP-1 insurance coverage across Medicare, Medicaid, and commercial plans — the federal-state coverage framework and how PA Medicaid fits within the broader picture.
• New Jersey Medicaid GLP-1 coverage (2026): dual-authority explicit exclusion + fiscal transparency — NJ is the closest operational architecture comparator to PA: both states have 5–7 MCOs, a Statewide PDL with binding DURB/P&T protocols, and the same three non-weight-loss carve-out indications (Wegovy MACE + Wegovy MASH + Zepbound OSA). The critical difference: PA terminated obesity coverage on January 1, 2026 after 34 months; NJ never had obesity coverage to terminate. NJ also published an unprecedented DMAHS fiscal-impact memo ($37.7M net state-fund cost to extend full coverage) and has active reversal-direction legislation (A3369, 222nd Legislature) pending.
• Massachusetts Medicaid (MassHealth) GLP-1 coverage (2026): two-phase termination policy-reversal — the closest analog to PA in the series. Both are policy-reversal states terminating chronic-weight-management coverage in 2026: PA after 34 months (January 1, 2026; 38-day notice; 55 Pa. Code § 1121.54 already in place), MA after 30 months (July 1, 2026; 110-day notice; 130 CMR 406.413(B) amendment “anticipated forthcoming” as of May 10, 2026). MA's Phase 2 architecture (MACE BMI ≥ 27 + MASH + OSA BMI ≥ 30) is broader than PA's on the OSA dimension (PA requires BMI ≥ 35 for OSA; MA requires BMI ≥ 30). The comparison illuminates how two states with nearly identical policy trajectories can differ on the procedural details that matter for provider submissions.