Utah Medicaid GLP-1 Coverage 2026: Legislative Pilot-Program Coverage with 6/30/2026 Sunset Date + Unified 11-Part PA Form Covering Saxenda, Wegovy, and Zepbound Across 6 Indications

TL;DR

Utah Medicaid (administered by the Utah Department of Health and Human Services) is structurally unique in the 37-state series: chronic-weight-management coverage exists, but only through June 30, 2026 under a legislative pilot program. The Utah Medicaid Pharmacy PA form — titled “GLP-1 Medications for Weight Loss and Other Indications (Saxenda, Wegovy, Zepbound)” and last updated January 1, 2026 — requires three separate provider attestations (Part 2 adult, Part 3 pediatric, Part 10 reauthorization) verbatim:

“Does the provider attest that they are aware that coverage for weight management is part of a legislative pilot program and may not continue past 6/30/2026?”

The Authorization Duration section states verbatim:

“Obesity (Saxenda/Zepbound/Wegovy): Up to and no later than 6/30/2026*, initial and reauthorizations

* Coverage for weight-loss is part of a pilot program and may not continue past 6/30/2026.”

What this means in practice (May 15, 2026): there are ~45 days remaining in the current pilot authorization window. Patients and prescribers initiating Saxenda, Wegovy, or Zepbound for chronic weight management in Utah right now should plan for therapy continuity questions ahead of June 30, 2026. Three possible outcomes after the sunset:

• The Utah Legislature extends the pilot (the most common outcome for successful Medicaid pilot programs), potentially with modifications to criteria, age scope, or covered drugs.
• The Utah Legislature converts the pilot to a permanent Medicaid benefit.
• The pilot sunsets without renewal, ending Saxenda / Wegovy / Zepbound coverage for chronic weight management in Utah Medicaid.

Three indication-permanent carve-outs continue indefinitely post-sunset (NOT subject to the June 30, 2026 deadline):

Architectural distinctive features:

• Unified 11-part PA form. Utah uses a single document covering Saxenda + Wegovy + Zepbound across six indications (adult weight loss, pediatric weight loss, Wegovy MACE, Zepbound OSA, Wegovy MASH, plus reauthorization paths) in one PDF. Arkansas (Pattern #34) uses three separate DUR-Board documents; West Virginia (Pattern #36) combines Wegovy CV+MASH in one document but separates Zepbound OSA. Utah is the only state in the 37-state series with all indications in one form.
• Strictest OSA criteria in the series. Zepbound OSA requires in-lab attended PSG (not home sleep test) for AHI documentation AND ≥ 70% PAP adherence over the last 6 months. WV Pattern #36 only requires CPAP counseling; AR Pattern #34 requires CPAP failure but does not specify a 70% adherence threshold. Utah's 70% PAP-adherence bar is unique.
• Dual-modality MASH confirmation. Wegovy MASH requires both a FIB-4 score consistent with F2 or F3 fibrosis (adjusted for age) AND ONE of: liver biopsy, vibration-controlled transient elastography (VCTE), enhanced liver fibrosis (ELF) score, or magnetic resonance elastography (MRE). Most other states accept biopsy OR imaging singly.
• Guideline-recommended MACE secondary prevention required. Wegovy MACE coverage requires the patient to be concurrently taking guideline-recommended cardiovascular secondary-prevention measures (typically statin + antiplatelet + BP control). Most other states do not explicitly require concurrent guideline-recommended prevention as a coverage gate.
• Pediatric coverage limited to Saxenda + Wegovy. Pediatric (ages 12–17) weight management is available through the pilot for Wegovy or Saxenda only — Zepbound is NOT a pediatric-eligible drug under Utah Medicaid even during the pilot period.

Medicaid expansion status: Utah voters approved Proposition 3 (full Medicaid expansion to 138% FPL) by ballot initiative in November 2018. After 2019 legislative modifications (Senate Bills 96 and 4001), Utah implemented full Medicaid expansion effective January 1, 2020. Approximately 350,000–400,000 Utahns are enrolled in Medicaid as of 2026 including the expansion population.

Pharmacy PA submission: fax the completed form with chart notes and lab results to Pharmacy Prior Authorization Team at 855-828-4992. Prescriber NPI required.

1. The June 30, 2026 pilot program sunset

The defining feature of Utah Medicaid's GLP-1 coverage architecture is the legislative pilot program with an explicit sunset date of June 30, 2026. The pilot operates at the Utah Medicaid pharmacy benefit level and is operationalized through the Utah Medicaid Pharmacy Prior Authorization Request Form for “GLP-1 Medications for Weight Loss and Other Indications.”

1.1 Verbatim sunset language from the PA form

The pilot-sunset attestation appears three times in the PA form — signaling that Utah Medicaid wants prescribers to be unambiguously aware of the sunset risk before initiating therapy and at each reauthorization:

• PA form Part 2 (adult weight loss, item 10): “Does the provider attest that they are aware that coverage for weight management is part of a legislative pilot program and may not continue past 6/30/2026?”
• PA form Part 3 (pediatric weight loss, item 14): Same attestation language for pediatric requests.
• PA form Part 10 (weight-loss reauthorization, item 12): Same attestation language at reauthorization.

The Authorization Duration section of the PA form states verbatim:

“Obesity (Saxenda/Zepbound/Wegovy): Up to and no later than 6/30/2026*, initial and reauthorizations

MACE (Wegovy): Up to six (6) months initial authorization, up to twelve (12) months reauthorization

Moderate/Severe OSA (Zepbound): Up to twelve (12) months, initial and reauthorizations

MASH (Wegovy): Up to six (6) months initial authorization, up to twelve (12) months reauthorization

* Coverage for weight-loss is part of a pilot program and may not continue past 6/30/2026.”

1.2 What we know vs. what we don't

Verified primary-source facts:

• Coverage of Saxenda, Wegovy, and Zepbound for chronic weight management in Utah Medicaid is part of a legislatively-authorized pilot program.
• The current sunset date is June 30, 2026.
• No initial PA or reauthorization for chronic weight management can extend past June 30, 2026 under the current pilot authorization.
• The three indication-permanent carve-outs (Wegovy MACE, Zepbound OSA, Wegovy MASH) are NOT subject to the sunset and operate on standard PA approval periods (6 months initial / 12 months reauth for Wegovy MACE and Wegovy MASH; 12 months initial AND reauth for Zepbound OSA).

What the PA form does NOT specify:

• The specific Utah statute or session law authorizing the pilot.
• The pilot's renewal mechanism — whether the Utah Legislature must affirmatively act to extend, or whether the Utah Medicaid program can administratively continue coverage under a different authority post-sunset.
• Whether the pilot was funded by a specific appropriation that also sunsets June 30, 2026, or whether funding continues independently.
• The fiscal year 2026 spend or beneficiary count under the pilot.

Patients, prescribers, and pharmacy staff should monitor Utah Medicaid pharmacy bulletins and Utah Legislature session updates in May and June 2026 for renewal status. As of the article's verification date (May 15, 2026), the pilot is operational and PAs are being approved under it through June 30, 2026.

2. Universal criteria across all 6 indication pathways (PA Form Part 1)

All six PA-form pathways (adult weight loss, pediatric weight loss, Wegovy MACE, Zepbound OSA, Wegovy MASH) share the same Part 1 universal criteria. Verbatim from the PA form:

“PART 1 - Criteria for Approval: (All of the following criteria must be met)

1. What is the patient's current Weight, Height, BMI, Age?

2. Is the patient on a medically appropriate exercise program and an appropriate calorie-restricted diet, that they will continue while using the medication presented in the chart note?

3. Does the provider attest that the patient has no personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2?

4. Does the provider attest that the patient is NOT pregnant?

5. Does the provider attest that the patient is NOT taking another glucagon-like peptide-1 (GLP-1) receptor agonist, a glucose-dependent insulinotropic peptide (GIP), or a dipeptidyl peptidase-4 (DPP4) inhibitor?

6. Does the prescriber attest that doses of the medication will be titrated to the required minimum dose required for reauthorization, within 6 months of initiation, as appropriate?”

These six universal criteria mirror the FDA-label contraindications for Wegovy, Saxenda, and Zepbound:

• MTC/MEN2 contraindication — standard FDA label warning for all GLP-1 receptor agonists.
• Pregnancy exclusion — standard FDA Category warning.
• Concurrent GLP-1/GIP/DPP-4 exclusion — prevents formulary cross-utilization between Antiobesity Select Agents and Hypoglycemics-Incretin Mimetics classes, and reinforces one-at-a-time rule across drug classes.
• Lifestyle attestation — reduced-calorie diet and increased physical activity must be in place AND continuing during therapy.
• Dose titration commitment — doses must be titrated to the required minimum maintenance dose within 6 months of initiation. This prevents low-dose maintenance prescribing and ensures patients reach the therapeutic dose range for the FDA-approved indication.

The PA form's Part 1 also includes the FDA suicidality monitoring note verbatim:

“The FDA has been evaluating reports of suicidal thoughts or actions in patients treated with glucagon-like peptide-1 receptor agonists (GLP-1 RAs). A preliminary evaluation has not found evidence that the use of these medicines causes suicidal thoughts or actions, but the FDA is continuing to investigate this issue. Patients should not stop taking GLP-1 RAs without consulting their health care provider. Health care providers should monitor and advise patients using GLP-1 RAs to report new or worsening depression, suicidal thoughts, or any unusual changes in mood or behavior.”

3. Adult weight management criteria (PA Form Part 2)

“PART 2 - Adult Weight Loss - Additional Criteria for Approval: (All of the following criteria must be met)

8. Is the patient 18 years of age or older?

9. Does the patient have a diagnosis of one of the following?

Obesity (BMI ≥ 30 kg/m²)

Overweight (BMI 27-29.9 kg/m²) and at least one weight-related comorbidity (e.g. hypertension, dyslipidemia, etc.) Comorbidities: ______________________________________

10. Does the provider attest that they are aware that coverage for weight management is part of a legislative pilot program and may not continue past 6/30/2026?”

Operational note: Utah does not require additional comorbidity-specific lab values (HbA1c for diabetes, lipid panel for hyperlipidemia, sleep study for OSA) at the BMI 27–29.9 tier — the provider attests to the comorbidity diagnosis on the form. This is more permissive than states like Mississippi (Pattern #35), which requires claims-history or lab-value confirmation of comorbidities. Utah's permissive approach reflects the pilot-program nature of the coverage.

4. Pediatric weight management criteria (PA Form Part 3)

“PART 3 - Pediatric Weight Loss - Additional Criteria for Approval: (All of the following criteria must be met)

11. Is the patient 12 to 17 years old?

12. Is the request for Wegovy or Saxenda?

13. Is the patient's BMI ≥ 95th percentile for their age and sex?

14. Does the provider attest that they are aware that coverage for weight management is part of a legislative pilot program and may not continue past 6/30/2026?”

Critical operational facts for the Utah pediatric weight management pathway:

• Ages 12–17 only. No coverage for ages under 12 or 18+.
• Wegovy or Saxenda only. Zepbound is excluded from pediatric coverage in Utah even during the pilot. This aligns with current FDA pediatric labeling (Wegovy approved ages 12+; Saxenda approved ages 12+ with body weight requirements; Zepbound not pediatric-approved as of May 2026).
• BMI ≥ 95th percentile for age and sex — the standard CDC growth-chart obesity definition for pediatric patients. The form does not reproduce the CDC table inline (unlike Mississippi Pattern #35, which embeds the CDC table in the PA form) but references the standard percentile definition.

Utah and Mississippi (Pattern #35) are the two states in the 37-state series with explicit pediatric chronic-weight-management Medicaid GLP-1 coverage. The two states differ in important ways:

• Utah: pilot-program with June 30, 2026 sunset; Wegovy and Saxenda only; BMI ≥ 95th percentile criterion; same PA form as adult.
• Mississippi: permanent coverage via SPA 23-0013 since July 1, 2023; Wegovy and Saxenda only; CDC growth-chart table embedded in PA form; Saxenda requires body weight > 60 kg additionally.

5. Wegovy MACE criteria (PA Form Part 4 — NOT subject to sunset)

“PART 4 - Wegovy for MACE - Additional Criteria for Approval: (All of the following criteria must be met)

15. Is the patient 18 years of age or older?

16. Does the patient have a Body Mass Index (BMI) of ≥ 27 kg/m²?

17. Does the patient have a past medical history of at least one of the following:

Myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)

Stroke (hemorrhagic or ischemic)

Symptomatic peripheral arterial disease, as evidenced by intermittent claudication with ankle-brachial index less than 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease

18. Is the patient currently taking guideline-recommended measures for the secondary prevention of a major adverse cardiovascular event (MACE)?”

Initial PA: up to 6 months. Reauthorization: up to 12 months, requires titration to Wegovy 2.4 mg dose AND ≥ 5% baseline body weight loss after 20 weeks (maintained) AND continued guideline-recommended MACE secondary prevention.

Two operationally distinctive Utah features:

• Past-MI flexibility: Utah accepts past myocardial infarction OR percutaneous coronary intervention (PCI) OR coronary artery bypass grafting (CABG) as the cardiac qualifying event. West Virginia (Pattern #36) and Arkansas (Pattern #34) require past MI more specifically. Utah's acceptance of PCI/CABG widens the qualifying population.
• Guideline-recommended secondary prevention required (item 18) — the patient must be concurrently taking guideline-recommended MACE secondary prevention measures (typically statin + antiplatelet + BP control for prior MI/stroke; ABI-appropriate management for PAD). Most other states in the 37-state series do not explicitly require concurrent guideline-recommended prevention as a coverage gate.

Note that Utah does NOT have the West Virginia HbA1c ≤ 6.5% diabetic-exclusion gate — T2D patients with established CVD can qualify for Wegovy MACE in Utah (subject to the Part 1 no-other-GLP-1/GIP/DPP-4 exclusion, which they would need to satisfy by going off any concurrent T2D-indicated GLP-1).

6. Zepbound OSA criteria (PA Form Part 5 — strictest in series)

“PART 5 - Zepbound for OSA - Additional Criteria for Approval: (All of the following criteria must be met)

19. Is the patient 18 years of age or older?

20. Is the medication being prescribed by or in consultation with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist?

21. Does the patient have a body mass index (BMI) of greater than or equal to 30 kg/m²?

22. Does the patient have a diagnosis of moderate-to severe obstructive sleep apnea (OSA) confirmed by an apnea-hypopnea index (AHI) of 15 or higher as determined by an in-lab attended sleep study or polysomnography (PSG)?

Baseline AHI score: __________________________

23. Has the patient been adherent to positive airway pressure (PAP) for at least 70% in the last 6 months and will continue on PAP in combination with Zepbound, unless intolerant or other rationale is given?”

Initial PA: up to 12 months. Reauthorization: up to 12 months, requires AHI decrease ≥ 20% from baseline OR shift to Mild Non-Symptomatic OSA (AHI < 5 OR AHI 5–14 with Epworth Sleepiness Scale ≤ 10); continued ≥ 70% PAP adherence.

Utah's OSA criteria are the strictest in the 37-state series:

• In-lab attended PSG required — not home sleep tests, not portable monitoring. This excludes patients who were diagnosed with OSA via home sleep test only. Utah is the only state in the series with this in-lab-PSG-only requirement.
• 70% PAP adherence in last 6 months required at initial PA — the patient must already be using PAP compliantly before Zepbound OSA approval. WV Pattern #36 only requires CPAP counseling (not adherence); AR Pattern #34 requires CPAP failure but does not specify adherence percentage. Utah's 70%-adherence bar reflects sleep-medicine clinical-practice standards for adequate PAP therapy.
• Specialist consultation required — neurologist, pulmonologist, otolaryngologist, or sleep medicine specialist must prescribe or consult. Primary-care physicians cannot independently prescribe Zepbound OSA in Utah.
• Reauthorization requires either ≥ 20% AHI reduction OR shift to Mild Non-Symptomatic OSA — with both clinical metric and symptom assessment (Epworth Sleepiness Scale).

Utah does NOT have the West Virginia T2D step-therapy bridge (which requires T2D patients to first fail a preferred T2D GLP-1 for 3 months before Zepbound OSA). Utah's no-concurrent-GLP-1 rule at Part 1 item 5 effectively requires T2D patients to be off any T2D-indicated GLP-1 to qualify for Zepbound OSA, but does not require demonstrated treatment failure of a T2D GLP-1 first.

7. Wegovy MASH criteria (PA Form Part 6 — dual-modality required)

“PART 6 - Wegovy for MASH - Additional Criteria for Approval: (All of the following criteria must be met)

24. Is the patient 18 years of age or older?

25. Does the patient have a diagnosis of metabolic dysfunction associated steatohepatitis (MASH), or formerly known as noncirrhotic nonalcoholic steatohepatitis (NASH)?

26. Is the medication being prescribed by or in consultation with a gastroenterologist, hepatologist, or other liver disease specialist?

27. Does the patient have moderate to advanced liver fibrosis (stage F2 to F3) as confirmed by:

a. A FIB-4 score consistent with stage F2, or F3 fibrosis adjusted for age AND

b. ONE of the following:

A liver biopsy

Vibration-controlled transient elastography (VCTE)

Enhanced liver fibrosis (ELF) score

Magnetic resonance elastography (MRE)

28. Does the provider attest the patient does NOT have ANY of the following?

a. Decompensated cirrhosis

b. Moderate to severe hepatic impairment (Child-Pugh Class B or C)

c. Any other liver disease (e.g., hepatocellular carcinoma, hepatitis)”

Initial PA: up to 6 months. Reauthorization: up to 12 months, requires Wegovy maintenance on 2.4 mg (or 1.7 mg if higher dose intolerable after 17 weeks) AND updated chart notes demonstrating positive clinical response (improvement in symptoms and/or improvement in routine monitoring such as FIB-4 score or serum aminotransferases).

Utah's MASH dual-modality requirement is structurally distinctive. The patient must satisfy BOTH:

• FIB-4 score consistent with F2 or F3 fibrosis adjusted for age — a calculated index based on age, AST, ALT, and platelet count.
• ONE of: liver biopsy, VCTE (FibroScan), ELF score, or MRE — an imaging or biopsy modality.

West Virginia (Pattern #36) accepts biopsy OR FibroScan/MRE singly without a parallel FIB-4 requirement. Arkansas (Pattern #34) similarly. Utah is the only state in the series requiring both a blood-based fibrosis index AND an imaging/biopsy modality — a more rigorous fibrosis-confirmation standard.

Liver-disease exclusions (item 28) are also more specific than other states: decompensated cirrhosis, Child-Pugh Class B or C (moderate-to-severe hepatic impairment), and any other liver disease including hepatocellular carcinoma or hepatitis. Patients with viral hepatitis (HBV or HCV) would not qualify for Wegovy MASH in Utah even if they meet F2–F3 fibrosis criteria, because viral hepatitis is “another liver disease” under item 28(c).

8. Reauthorization criteria (PA Form Parts 7–11)

Reauthorization across all indications shares a common Part 7 framework (current weight/height/BMI/age, continued adherence to exercise and calorie-restricted diet) plus indication-specific additional criteria in Parts 8–11.

8.1 Wegovy MACE reauthorization (Part 8)

• Patient titrated up to or taking the Wegovy 2.4 mg dose.
• Initial weight loss of ≥ 5% from baseline body weight after 20 weeks AND maintained.
• Continued guideline-recommended MACE secondary prevention.

8.2 Zepbound OSA reauthorization (Part 9)

• AHI decrease from baseline ≥ 20% OR shift to Mild Non-Symptomatic OSA (defined as AHI < 5 OR AHI 5–14 with Epworth Sleepiness Scale ≤ 10).
• ≥ 70% PAP adherence in last 6 months AND continued PAP use with Zepbound (unless intolerant or other rationale).

8.3 Adult/pediatric weight loss reauthorization (Part 10)

• ≥ 5% weight loss from baseline.
• Patient titrated up and currently taking at least the minimum required maintenance dose after 6 months of treatment:
  • Saxenda (adult 18+): 3 mg daily
  • Saxenda (pediatric 12–17): 2.4 mg daily
  • Wegovy: 1.7 mg per week
  • Zepbound: 5 mg per week
• Provider pilot-sunset attestation (third occurrence in the form).

8.4 Wegovy MASH reauthorization (Part 11)

• Patient maintained on Wegovy 2.4 mg (or 1.7 mg if higher dose cannot be tolerated after 17 weeks).
• Updated chart notes demonstrating positive clinical response (improvement in symptoms; improvement in routine monitoring such as FIB-4 score or serum aminotransferases).

9. Utah vs. the 37-state taxonomy

9.1 Utah's structural uniqueness

• Only state with a legislative pilot-program sunset date attached to chronic-weight-management coverage. The June 30, 2026 sunset creates an unusual time-sensitive coverage architecture.
• Only state with a unified PA form across all 6 GLP-1 indications. All other states use separate documents per indication (or combine two related indications, as WV does with Wegovy CV+MASH).
• Strictest OSA criteria in the series: in-lab attended PSG only + 70% PAP adherence required.
• Only state with dual-modality MASH confirmation (FIB-4 PLUS one imaging/biopsy).
• Concurrent guideline-recommended MACE secondary prevention required — explicit gate not used by most other states.

9.2 Closest peers

• Mississippi (Pattern #35) — the other state in the series with operationalized pediatric (ages 12+) chronic-weight-management coverage. MS coverage is permanent (via SPA 23-0013 effective July 1, 2023); UT coverage is pilot with June 30, 2026 sunset. Both cover Wegovy + Saxenda for ages 12+ (UT excludes Zepbound from pediatric; MS does not cover Zepbound at all).
• West Virginia (Pattern #36) — same three FDA-label carve-outs (Wegovy CV + Wegovy MASH + Zepbound OSA). UT adds chronic-weight-management coverage during pilot; WV does not. UT requires 70% PAP adherence for OSA; WV only requires CPAP counseling. UT requires dual-modality MASH confirmation; WV accepts biopsy or imaging singly.
• Oklahoma (Pattern #24) — four FDA-label carve-outs (adds Imcivree monogenic-obesity). OK uses OU College of Pharmacy / PMC for PA; UT uses the standard Utah Medicaid Pharmacy PA Team. Both states are expansion states (OK via SQ 802 July 2021; UT effective January 1, 2020).
• Arkansas (Pattern #34) — three FDA-label carve-outs via three separate DUR-Board PA documents. AR has ACT 628 legislative-ratification layer affirming exclusion of chronic weight management; UT has the opposite legislative posture — a pilot program affirming temporary coverage.

10. Appeals pathway and pilot-sunset planning

Utah Medicaid appeals run through the Utah Department of Health and Human Services administrative-hearing process and 42 C.F.R. § 431 Subpart E (federal Fair Hearings framework).

Practical denial-recovery path for a Utah Medicaid GLP-1 PA denial:

1. Contact Pharmacy PA Team at 855-828-4992 to verify denial rationale (often documentation deficiency, not categorical denial).
2. Re-submit PA with additional documentation: ensure all six Part 1 universal criteria attested; ensure indication-specific Part 2–6 documentation complete and specific. For OSA in particular, ensure the in-lab attended PSG report (not home test) is attached and the 70% PAP adherence report from the CPAP device is downloaded and included. For MASH, ensure both FIB-4 calculation AND one imaging/biopsy modality are documented.
3. If denial stands, file request for fair hearing through Utah DHHS Medicaid.
4. Hearing before an administrative law judge with the right to representation and to introduce evidence.
5. Final agency decision.
6. Judicial review in Utah district court.

10.1 Pilot-sunset planning

For patients currently on Saxenda, Wegovy, or Zepbound for chronic weight management under the Utah Medicaid pilot, planning ahead of the June 30, 2026 sunset is operationally important:

• Monitor Utah Medicaid pharmacy bulletins through May and June 2026 for pilot renewal announcements.
• Discuss with prescriber whether a transition to a different indication-permanent pathway is clinically appropriate (e.g., if the patient has established CVD, transition to Wegovy MACE; if the patient has confirmed F2–F3 MASH, transition to Wegovy MASH; if the patient has confirmed moderate-to-severe OSA, transition to Zepbound OSA).
• Plan for potential out-of-pocket cash-pay coverage starting July 1, 2026 if the pilot does not renew — NovoCare offers Wegovy at $349/month ongoing self-pay (or $199/month for new patients first 2 months); LillyDirect offers Zepbound vials at $299–$699/month depending on dose; compounded alternatives also available.
• If pilot does not renew, an appeal of a post-sunset chronic-weight-management denial is structurally very unlikely to succeed — the denial would be anchored to the absent legislative authority for coverage and would not be overturnable at the agency level.

Frequently asked questions