Wisconsin Medicaid (ForwardHealth / BadgerCare Plus) GLP-1 Coverage (2026): Pattern #19 — Positive Coverage With Broadest Published AOM PA Criteria + 2-Lifetime-Attempt Cap + BMI < 24 Renewal-Revocation + No PBM Intermediary + Dual-Eligibles Medicare Part D Gap Fill

TL;DR

Wisconsin Medicaid (ForwardHealth, encompassing BadgerCare Plus, Medicaid SSI, and SeniorCare) covers GLP-1 receptor agonists for adult chronic weight management. Coverage has been operationally continuous since at least March 2023 and has expanded twice since then: Zepbound was added effective July 1, 2024, and generic orlistat was added effective July 1, 2025.

The currently covered chronic-weight-management AOMs, published verbatim in ForwardHealth Update 2025-16 (June 2025), are Benzphetamine, Diethylpropion, Orlistat (as of July 1, 2025), Phendimetrazine, Phentermine, Evekeo, Saxenda, Wegovy, Xenical, and Zepbound. Coverage is gated by prior authorization on Form F-00163 (07/2024) with BMI thresholds aligned to the FDA label (BMI ≥ 30, or BMI ≥ 27 with two or more comorbidities for adults 18+).

Two features make Wisconsin uniquely restrictive in the 19-state series: (1) a published 2-lifetime-attempts cap — after two PA cycles with any covered AOM (for any reason, including side effects), future PA is denied for life with no appeal rights; and (2) a BMI < 24 renewal-revocation rule — if a patient succeeds on therapy and drops below BMI 24 at any PA renewal, coverage is automatically terminated. These rules transform Wisconsin from a “broad coverage” state into a broad eligibility, capped utilization state.

Two features make Wisconsin uniquely favorable in the series: (3) no PBM intermediary — the pharmacy benefit is centrally carved out to the state, with no MCO-level PDL override possible; and (4) explicit dual-eligibles coverage — ForwardHealth covers AOMs for members enrolled in Medicare Part D, filling the federal Part D AOM exclusion gap that no other state in the series has addressed verbatim.

Last verified: May 10, 2026. Primary sources: ForwardHealth Update 2025-16 (June 2025); ForwardHealth Update 2024-16 (June 2024); Form F-00163 (07/2024); Wis. Admin. Code § DHS 107.10 (effective March 1, 2026); Wis. Stat. § 49.45(49); PSW ForwardHealth Anti-Obesity Drug Coverage Toolkit; KFF January 2026 Medicaid GLP-1 coverage tracker.

Pattern #19 — Third positive-coverage state: where Wisconsin fits in the 19-state series

This is the 19th installment in a 50-state Medicaid GLP-1 coverage series. Wisconsin is the third state in the series whose primary-source documentation confirms positive coverage for the chronic-weight-management FDA indication — joining North Carolina (Anchor #9, double-reversal) and Tennessee (Anchor #13, formal rulemaking expansion). The three positive-coverage states occupy a distinct cluster in the 19-state taxonomy, but their policy architectures differ sharply:

The paradox Wisconsin presents is structural: it is simultaneously the most permissive on initial entry (FDA-label-aligned BMI thresholds, pediatric coverage to age 12, no step-therapy gate between AOM classes) and the most restrictive on persistence (2-lifetime-attempts cap, BMI < 24 renewal-revocation, 12-month maximum continuous therapy per attempt). No other state in the 19-state series publishes both restrictions verbatim in a primary-source PA criteria document.

Wisconsin’s coverage predates Tennessee’s by approximately 27 months (Wisconsin: March 2023 PDL review; Tennessee: August 1, 2025 emergency rule). It predates North Carolina’s by approximately 17 months (NC SPA effective August 1, 2024). Wisconsin is therefore the longest-running continuous positive-coverage state in the series — and the only one of the three that has never experienced a termination event.

The article writer’s taxonomy note: Wisconsin’s regulatory instrument (Wis. Admin. Code § DHS 107.10) contains no anorectic-drug or weight-loss-drug exclusion language. This is structurally distinct from the exclusion-anchored states (Texas, Illinois, Indiana, New York) that reproduce 42 U.S.C. § 1396r-8(d)(2)(A) at the state code level. Wisconsin has affirmatively declined to invoke the federal optional-exclusion authority for the AOM class as a whole; the prior-authorization gate is the operational instrument, not a categorical bar.

The 6 covered AOMs under F-00163 — verbatim from ForwardHealth Update 2025-16

The operative covered-AOM list is published in ForwardHealth Update 2025-16 (June 2025), effective July 1, 2025. The Update states verbatim:

“PA requests for the following anti-obesity drugs must be submitted on the Prior Authorization Drug Attachment for Anti-Obesity Drugs form, F-00163 (07/2024):

• Benzphetamine
• Diethylpropion
• Orlistat
• Phendimetrazine
• Phentermine
• Evekeo
• Saxenda
• Wegovy
• Xenical
• Zepbound

Anti-obesity drugs are covered for dual eligibles enrolled in a Medicare Part D Prescription Drug Plan.”

Orlistat (generic) is a 2025 addition. The Update notes verbatim: “Effective July 1, 2025, ForwardHealth will cover orlistat, the generic drug for Xenical.” Before July 2025, the 2024 policy explicitly excluded generic orlistat. This reversal is a continuing coverage-broadening event.

Zepbound was added effective July 1, 2024 per ForwardHealth Update 2024-16 — the first time tirzepatide appeared on the ForwardHealth AOM-covered list, approximately eight months after FDA approval (November 2023). Wegovy and Saxenda have been covered since at least the March 2023 PDL review (Update 2023-09).

What is NOT covered: Update 2024-16 lists verbatim non-coverage for “any brand name innovator single ingredient phentermine products,” over-the-counter AOMs, and AOMs “when used for conditions other than weight loss” (with explicit carved-in exceptions for Wegovy MACE, Wegovy MASH, and Zepbound OSA). Contrave (naltrexone/bupropion) is absent from the F-00163 covered-drug list; its coverage status is [NOT VERIFIED] and should not be assumed.

PA clinical criteria under F-00163 (07/2024)

Form F-00163 is the gating instrument for all ten chronic-weight-management AOM PA requests. The clinical criteria are:

Element 21 — Age minimums: “Members must be 18 years of age or older for approval of PA requests for anti-obesity drugs, except for Evekeo, Saxenda, Wegovy, and Xenical. Members must be 12 years of age or older to take Evekeo, Saxenda, Wegovy, and Xenical.”

Elements 22-25 — Categorical exclusions: Member must not be pregnant or nursing; must not have a history of an eating disorder (anorexia, bulimia, or binge eating disorder); prescriber must have determined no medical or medication contraindications; member must not have a history of substance abuse or misuse (for controlled-substance AOMs).

Element 26A: “The member is 18 years of age or older (or 12 years of age or older for Evekeo requests only) and has a BMI greater than or equal to 30.”

Element 26B: “The member is 18 years of age or older (or 12 years of age or older for Evekeo requests only) and has a BMI greater than or equal to 27 but less than 30 and has two or more of the following risk factors”: dyslipidemia, hypertension, sleep apnea, type 2 diabetes mellitus, or cardiovascular disease (defined by history of at least one of: myocardial infarction, coronary revascularization, angina pectoris, stroke, intermittent claudication with ABI ≤ 0.9, peripheral arterial revascularization, or amputation due to atherosclerotic disease).

Element 26C (Saxenda, ages 12–17): “The member has a body weight above 132 pounds and a BMI corresponding to 30 or greater for adults by international cut-offs.”

Element 26D (Wegovy and Xenical, ages 12–17): “The member has a BMI greater than or equal to the 95th percentile standardized by age and sex.”

Element 27 — Treatment plan: “Has the member participated in a weight loss treatment plan (for example, nutritional counseling, an exercise regimen, or a calorie-restricted diet) in the past six months, and will the member continue to follow this treatment plan while taking an anti-obesity drug?”

One member can use only one AOM at a time. Update 2024-16 states verbatim: “PA requests for anti-obesity drugs will only be approved for one anti-obesity drug per member. ForwardHealth does not cover treatment with more than one anti-obesity drug.”

The 2-lifetime-attempts cap — the most restrictive persistence rule in the 19-state series

Wisconsin is the only state in the 19-state series whose primary-source PA criteria explicitly publish a per-drug lifetime maximum for chronic-weight-management AOMs. The cap is documented verbatim in ForwardHealth Update 2024-16 with the same operative sentence for each covered drug:

Saxenda: “ForwardHealth allows only two weight loss attempts with Saxenda during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

Wegovy: “ForwardHealth allows only two weight loss attempts with Wegovy during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

Zepbound: “ForwardHealth allows only two weight loss attempts with Zepbound during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

Xenical: “ForwardHealth allows only two weight loss attempts with Xenical during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

Benzphetamine, Diethylpropion, Phendimetrazine, Phentermine: “ForwardHealth allows only two weight loss attempts with this group of drugs (benzphetamine, diethylpropion, phendimetrazine, and phentermine) during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

Evekeo: “ForwardHealth allows only two weight loss attempts with Evekeo during a member’s lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.”

The cap applies per drug, not cross-drug. A member who has used two attempts of Saxenda is not automatically barred from a first attempt at Wegovy or Zepbound. But once two attempts of any single drug are exhausted — regardless of whether discontinuation was due to side effects, lack of efficacy, patient preference, drug shortage, or any other reason — ForwardHealth will return future PA requests for that drug as noncovered services. There is no appeal right for noncovered services (distinct from PA denials, which carry fair-hearing appeal rights through the Wisconsin Department of Administration Division of Hearings and Appeals).

Per-drug PA durations before the 2-attempt cap terminates coverage:

Critical framing for patients: The 2-attempt cap is not reset if a member switches prescribers, changes HMOs, or moves to a different county. It is a lifetime member-level restriction tracked by ForwardHealth. Tennessee, North Carolina, and every other positive-coverage state in the series publish no equivalent lifetime cap in their primary-source PA criteria documents. The cap also applies to drugs a member discontinued early: a 30-day trial of Wegovy that was stopped due to nausea counts as one attempt.

The three cap-exempt pathways are Wegovy for MACE risk reduction, Wegovy for MASH (noncirrhotic F2-F3), and Zepbound for moderate-to-severe OSA. These special-indication pathways have no lifetime limit. This is the structural safety valve in the Wisconsin policy: a patient who has exhausted both lifetime chronic-weight-management attempts may still qualify for Wegovy or Zepbound coverage under a special indication if the clinical criteria are met.

The BMI < 24 renewal-revocation rule — the success paradox

ForwardHealth Update 2024-16 states verbatim:

“PA requests for anti-obesity drugs will not be renewed if a member’s BMI is below 24.”

The PSW ForwardHealth Anti-Obesity Drug Coverage Toolkit confirms and annotates the rule verbatim:

“PA requests for anti-obesity drugs will NOT be renewed if a member’s BMI is < 24.

This does NOT apply when the anti-obesity drug is being used for a special indication (i.e. MACE, MASH, or OSA).”

Wisconsin is the only state in the 19-state series that codifies a BMI floor for PA renewal that operates as a coverage termination trigger when a patient succeeds. This rule creates a structural paradox: a Wisconsin Medicaid member who responds well to therapy and drops below BMI 24 will have their AOM PA non-renewed at the next renewal cycle, even if the member and prescriber both prefer continuation.

To put this in clinical context: BMI 24 corresponds to the upper boundary of the “normal weight” range (BMI 18.5–24.9). The FDA label for Wegovy, Zepbound, and Saxenda does not contain a BMI-floor renewal restriction; the FDA labels generally permit continuation as clinically appropriate. Wisconsin’s BMI < 24 rule is more restrictive than any FDA label requirement for any approved AOM and has no counterpart in any other positive-coverage state in the series.

Practical implications for patients on therapy:

• A member starting at BMI 34 who reaches BMI 23.8 by month 11 will be denied renewal at month 12 under the BMI < 24 rule — despite having demonstrated excellent clinical response and despite the prescriber’s preference for maintenance dosing.
• The rule operates at every PA renewal cycle (every 180 days for Saxenda/Wegovy/ Zepbound renewal). Once BMI drops below 24, there is no provision for the prescriber to request an exception under the chronic-weight-management pathway.
• The special-indication exemption (MACE, MASH, OSA) provides one off-ramp: if the patient has established cardiovascular disease or MASH or sleep apnea, the prescriber can shift to the special-indication PA pathway, which has no BMI floor for renewal. The chronic-weight-management BMI < 24 rule does not apply to those pathways.
• Weight regain after discontinuation is a well-documented clinical phenomenon for GLP-1 drugs. The Wisconsin policy structure means that a patient who succeeds, loses coverage, and regains weight may subsequently face a second attempt-count charge if they restart therapy.

No PBM intermediary — Wisconsin’s unique direct-state-administration pharmacy benefit

Wisconsin is the only state in the 19-state series that administers the Medicaid pharmacy benefit directly through the state agency without a third-party PBM intermediary. This structural fact has direct operational consequences for GLP-1 access.

In most states in this series, the pharmacy benefit is carved to a PBM contractor (Tennessee uses OptumRx statewide for all four MCOs; Virginia uses Prime Therapeutics for FFS; Indiana uses OptumRx; Maryland uses MCO-contracted PBMs under the HealthChoice managed-care model). Wisconsin operates differently: the Division of Medicaid Services, within the Department of Health Services, administers pharmacy claims directly through the ForwardHealth claims management system (Gainwell Technologies operates the MMIS as a technology contractor, not as a PBM making coverage decisions). The PA decision-making authority sits with DHS, not with a private PBM.

MHS Health Wisconsin, a BadgerCare Plus HMO, confirms the carve-out structure verbatim: “The pharmacy benefit for members of BadgerCare Plus (Standard, Benchmark and Core plans) and Medicaid SSI is managed by the state of Wisconsin.” This means:

• There is no MCO-level PDL that can override the ForwardHealth Preferred Drug List for AOM coverage. HMO enrollment does not affect AOM access.
• The Drug Authorization and Policy Override (DAPO) Center at 800-947-9627 is the single statewide PA call center for all Medicaid pharmacy claims — operated by the state, not a PBM contractor.
• PA decisions are issued by ForwardHealth directly. When a PA is denied, the member can request a fair hearing directly from the Wisconsin Department of Administration Division of Hearings and Appeals (DHA) within 45 days — without first exhausting an HMO grievance process, because the pharmacy benefit is not HMO-administered.
• The statewide pharmacy carve-out ensures that Wisconsin Medicaid’s GLP-1 coverage policy is uniform across all 13 contracted HMOs in all counties. There is no geographic variation in AOM coverage rules — a member in Milwaukee County enrolled in Network Health Plan faces identical F-00163 clinical criteria as a member in Dane County enrolled in Dean Health Plan.

The Wisconsin state employee health plan (Group Insurance Board / Department of Employee Trust Funds) uses Navitus Health Solutions as its PBM — but that plan is structurally separate from Medicaid and governed by Wis. Stat. ch. 40, not Wis. Stat. § 49.45. The two plans must not be conflated. See the state employee plan section below.

Dual-eligibles Medicare Part D AOM coverage — unique in the 19-state series

ForwardHealth Update 2025-16 states verbatim (emphasis in the original):

“Anti-obesity drugs are covered for dual eligibles enrolled in a Medicare Part D Prescription Drug Plan.”

This is the most operationally significant unique finding in the Wisconsin evidence base. No other state in the 19-state series has addressed the dual-eligibles AOM question with this degree of verbatim clarity.

Why this matters: Federal Medicare Part D excludes anti-obesity drugs from coverage under 42 U.S.C. § 1395w-102(e)(2) (the Part D “Excluded Drugs” framework). Dual eligibles — members who have both Medicaid eligibility and Medicare Part D enrollment — would ordinarily have their prescription claims routed to Part D as the primary payer, which would then deny the AOM claim as an excluded drug. Most state Medicaid programs would then either cover the AOM as a Medicaid secondary-payer claim or deny it. Wisconsin’s Update 2025-16 confirms that ForwardHealth will cover AOM PA for dual eligibles as a Medicaid benefit, effectively filling the federal Part D AOM exclusion gap for Wisconsin’s approximately 90,000 dual-eligible enrollees who would otherwise have no drug coverage pathway for the AOM class.

Wisconsin’s dual-eligibles coverage is structurally enabled by the statewide pharmacy carve-out: because ForwardHealth administers pharmacy claims directly (not through a PBM that may defer to Part D as the primary payer), the coverage determination stays within the state Medicaid system. This is one of the most patient-favorable structural consequences of Wisconsin’s no-PBM-intermediary architecture for the GLP-1 access question.

No other state in the 19-state series has published an equivalent dual-eligibles AOM coverage clause verbatim in a primary-source update. North Carolina, Tennessee, and the other positive-coverage states do not address the dual-eligibles question verbatim in their primary-source PA criteria documents.

Statewide pharmacy carve-out — FFS for all enrollees regardless of HMO assignment

Wisconsin BadgerCare Plus operates a hybrid managed-care model: medical and behavioral-health benefits are delivered through 13 contracted HMOs in select counties, but the pharmacy benefit is centrally carved out to the state under ForwardHealth for all BadgerCare Plus, Medicaid SSI, and SeniorCare members regardless of HMO enrollment.

The structural consequence is uniform statewide AOM access. The ForwardHealth PDL — including the AOM-covered list on Form F-00163 — applies equally to every Wisconsin Medicaid enrollee. There are no MCO-specific formularies that can restrict or expand the AOM-covered list. The 13 contracted HMOs (including Anthem, Children’s Community Health Plan, CommunityConnect, Dean Health Plan, Group Health Cooperative of Eau Claire, Group Health Cooperative of South Central Wisconsin, iCare, MercyCare, MHS Health Wisconsin, Molina Healthcare, Network Health Plan, Quartz, Security Health Plan, and UnitedHealthcare Community Plan) administer the medical benefit but have no authority over pharmacy PA decisions for the AOM class.

The PA submission channels are published verbatim in Form F-00163A (07/2024):

“Prescribers may submit PA requests on a Prior Authorization Drug Attachment for Anti-Obesity Drugs form in one of the following ways:

• For PA requests submitted through the Drug Authorization and Policy Override Center, prescribers may call 800-947-9627.
• For PA requests submitted on the ForwardHealth Portal, prescribers may access www.forwardhealth.wi.gov.
• For PA requests submitted by fax, prescribers should submit a Prior Authorization Request Form (PA/RF), F-11018, and the Prior Authorization Drug Attachment for Anti-Obesity Drugs form to ForwardHealth at 608-221-8616.
• For PA requests submitted by mail, prescribers should submit a PA/RF and the Prior Authorization Drug Attachment for Anti-Obesity Drugs form to the following address: ForwardHealth, Prior Authorization, Ste 88, 313 Blettner Blvd, Madison WI 53784.”

ForwardHealth is required to issue a PA decision within 20 working days of receiving all necessary information, per the PSW toolkit. The DAPO Center phone channel (800-947-9627) is typically the fastest route for prescribers who need a rapid decision.

NC vs. TN vs. WI: the three positive-coverage state patterns compared

The 19-state series has now documented three states with confirmed primary-source positive coverage for the chronic-weight-management indication. They represent three structurally distinct policy architectures:

North Carolina (Anchor #9) — Double reversal within a single year

NC implemented coverage via SPA 2024-0032 effective August 1, 2024, which removed “weight loss” from its § 1396r-8(d)(2)(A) exclusion language. Coverage was terminated effective October 1, 2025 due to state funding shortfalls, then reinstated by gubernatorial directive effective December 12, 2025. The January 1, 2026 PDL lists Wegovy as Preferred. NC’s PA criteria do not publish a lifetime cap or a BMI < 24 renewal-revocation rule. The NC approach is a continuously contested political equilibrium — the termination and reinstatement pattern reflects budget pressure without a structural policy-stability mechanism.

Tennessee (Anchor #13) — Formal rulemaking expansion from categorical exclusion

TN expanded coverage from a categorical-exclusion baseline effective August 1, 2025 via emergency rule (Sequence 10-34-25), made permanent January 26, 2026. TennCare’s positive coverage is recent and rulemaking-anchored (codified in Tenn. Comp. R. & Regs. 1200-13-13-.04/.10 and 1200-13-14-.04/.10). TennCare uses OptumRx as the statewide PBM for all four MCOs. The TennCare PDL lists Wegovy and Zepbound as Preferred in the GLP-1 Weight Management Agents class with no published lifetime cap and no BMI < 24 renewal-revocation rule. TennCare’s approach is more expansive on persistence but newer in origin than Wisconsin’s.

Wisconsin (Anchor #19) — Long-running administrative coverage with restrictive persistence rules

WI implemented coverage via PDL review (Update 2023-09) in March 2023, using Wis. Admin. Code § DHS 107.10 and Wis. Stat. § 49.45 as the regulatory instruments — without a formal SPA or rule promulgation that required public comment specifically for the AOM class. Coverage has never been terminated. Wisconsin publishes the most detailed and most restrictive per-drug PA criteria in the positive-coverage cluster: six AOMs with explicit 2-lifetime-attempts caps, a BMI < 24 renewal-revocation rule, per-drug maximum continuous therapy limits (12 months for GLP-1s, 24 months for Xenical, 6 months for traditional stimulant AOMs), and explicit special-indication carve-outs. No PBM intermediary; direct state administration; dual-eligibles coverage verbatim.

The Wisconsin paradox formulated: Wisconsin offers the broadest published initial entry (FDA-label-aligned BMI threshold, pediatric coverage to age 12, pediatric BMI criteria for three drugs, no step-therapy gate between AOM classes, dual-eligibles coverage) but the tightest published persistence gate (2 lifetime attempts per drug, BMI < 24 renewal revocation, 12-month max per attempt, no appeal rights once the cap is triggered). This is a structurally different policy choice from North Carolina (broad entry and broad persistence, no lifetime cap) and Tennessee (broad entry and broad persistence, no lifetime cap, newer and rulemaking-anchored). The Wisconsin design reflects a fiscal-sustainability mechanism built into the PA criteria instrument rather than a budget-driven termination event.

Wisconsin state employee plan (GIB/ETF) — out-of-scope; AOM coverage not until January 1, 2027

The Wisconsin state employee health plan is administered by the Group Insurance Board (GIB) under the Department of Employee Trust Funds (ETF), using Navitus Health Solutions as the PBM. It is governed by Wis. Stat. ch. 40 — a completely separate statutory framework from the Medicaid authority at Wis. Stat. § 49.45. The GIB plan does not cover AOMs in 2025 or 2026.

A GIB memo dated October 15, 2024 (Item 13 of the November 13, 2024 Board meeting) describes the coverage decision process. The GIB approved AOM coverage for the state employee plan with a $200 copay effective January 1, 2027 only. State employees and their dependents who are enrolled in the GIB plan — not BadgerCare Plus — will need to wait until 2027 for AOM coverage through their employment-based insurance.

Wisconsin therefore operates two structurally divergent benefit designs in parallel: ForwardHealth Medicaid (positive coverage since March 2023, FDA-label-aligned thresholds) and the GIB state employee plan (no AOM coverage in 2025–2026, coverage with $200 copay approved for January 1, 2027). These are the same parallelism seen in other states (New Jersey: SHBP state employee plan covers non-diabetic GLP-1s while NJ FamilyCare Medicaid excludes them; Tennessee: TennCare covers Zepbound as Preferred while the state employee Caremark plan does not). In Wisconsin’s case, the asymmetry runs in the opposite direction: Medicaid covers, state employee plan does not (until 2027).

T2D GLP-1 pathway vs. AOM pathway — two separate PA tracks

ForwardHealth operates two structurally separate GLP-1 PA pathways. The AOM pathway (Form F-00163) covers Saxenda, Wegovy, Zepbound, Xenical, orlistat, Evekeo, and traditional stimulant AOMs for chronic weight management. The hypoglycemics GLP-1 class covers Ozempic, Trulicity, Victoza, Byetta, exenatide, Soliqua, Rybelsus, Mounjaro, and liraglutide for type 2 diabetes only (diagnosis-restricted via ICD-10 T2D codes).

ForwardHealth Update 2025-16 confirms the hypoglycemics GLP-1 class clinical criteria verbatim:

“Clinical criteria for approval of a PA request for a non-preferred hypoglycemics, GLP-1 agent are all of the following:

• The non-preferred drug is being prescribed in a manner consistent with the FDA-approved product labeling.
• The member has type 2 diabetes mellitus.
• The member’s hemoglobin A1c (HbA1c) was measured within the past six months.
• If the member is not currently using a hypoglycemics, GLP-1 agent, their most recent HbA1c is 6.5% or greater.

One of the following must be documented for at least two of the preferred hypoglycemics, GLP-1 agents:

• The member has taken the maximum dose of a preferred hypoglycemics, GLP-1 agent for at least three consecutive months and experienced an unsatisfactory therapeutic response in glycemic control.
• The member experienced a clinically significant adverse drug reaction with a preferred hypoglycemics, GLP-1 agent.”

Key distinction: The T2D GLP-1 class (Ozempic, Mounjaro, Victoza, etc.) has no lifetime cap and no BMI < 24 renewal-revocation rule. Those restrictions are specific to the AOM pathway. A member with both T2D and obesity who is prescribed Ozempic for glycemic control is on the T2D pathway, not the AOM pathway, and the 2-lifetime-attempts cap does not apply.

Wegovy appears in both pathways: Wegovy for the AOM chronic-weight-management indication (F-00163, subject to the 2-cap and BMI < 24 rule) and Wegovy for MACE risk reduction (separate PA form via Section VI of PA/DGA, no lifetime cap, DAPO Center phone submission not available). Mounjaro appears only in the T2D hypoglycemics class (non-preferred). Zepbound appears in the AOM class (preferred chronic weight management) and in the Zepbound OSA special-indication pathway.

Wisconsin in the 19-state Medicaid GLP-1 taxonomy

The 19 states profiled in this series span six structural patterns:

Within the positive-coverage cluster, Wisconsin is the clearest example of a state that used a PDL-review administrative mechanism (not a formal SPA or rule promulgation) to implement positive coverage — and then embedded fiscal sustainability directly into the PA criteria instrument. The 2-lifetime-attempts cap is the mechanism by which Wisconsin limits total program exposure while maintaining broad initial eligibility.

Excluded populations and non-covered drugs

The following populations and drugs are not covered under Wisconsin Medicaid’s AOM PA pathway, as documented by primary source:

• Members who have exhausted 2 lifetime attempts for a given AOM — PA will be returned as a noncovered service; no appeal rights. This is the most common structural exclusion unique to Wisconsin in the series.
• Members with BMI < 24 at renewal time — PA will not be renewed. The member may restart when BMI returns to ≥ 24, but the prior attempt counts against the 2-lifetime-attempts cap.
• Members under age 18 for most AOMs — except Evekeo (age ≥ 12), Saxenda (age ≥ 12 with weight > 132 lb and BMI ≥ 30 by Cole criteria), Wegovy (age ≥ 12 with BMI ≥ 95th percentile), and Xenical (age ≥ 12 with BMI ≥ 95th percentile).
• Pregnant or nursing members — F-00163 Element 22 is a categorical exclusion.
• Members with a history of eating disorders (anorexia, bulimia, binge eating disorder) — F-00163 Element 23 categorical exclusion.
• Over-the-counter AOMs — not covered. Brand-name innovator single-ingredient phentermine products — not covered.
• Contrave (naltrexone/bupropion) — absent from the F-00163 covered-drug list. Coverage status is [NOT VERIFIED] and should not be assumed.
• SeniorCare Level 2B members — SeniorCare levels vary by income; Level 2B has a higher copay structure. Verify eligibility tier before assuming AOM coverage applies identically to all SeniorCare levels.
• Wisconsin state employee plan members (GIB/ETF) — governed by a separate benefit design. No AOM coverage until January 1, 2027.

Patient action steps and the Wisconsin fair-hearing appeal pathway

Before submitting a PA request

1. Confirm your AOM attempt count with your prescriber before initiating a new PA. If you have previously received Medicaid-covered AOM therapy in Wisconsin, verify whether any prior approval cycles counted as a lifetime attempt. There is no public member portal for attempt-count lookup; request confirmation through the DAPO Center (800-947-9627) or your prescriber.
2. Confirm your current BMI. If your current BMI is below 24, a renewal PA for chronic-weight-management indications will not be approved. Ask your prescriber whether a special-indication pathway (MACE, MASH, or OSA) may apply if you have established cardiovascular disease, MASH, or sleep apnea.
3. Document your 6-month weight-loss treatment plan before your prescriber submits Form F-00163 (Element 27). Nutritional counseling records, exercise regimen documentation, or calorie-restricted diet logs constitute acceptable evidence.
4. Identify your PA submission channel: DAPO Center phone (800-947-9627), ForwardHealth Portal (forwardhealth.wi.gov), fax (608-221-8616), or mail (313 Blettner Blvd, Ste 88, Madison WI 53784). The DAPO Center is the fastest channel for urgent cases.
5. If prescribed by a specialist for Wegovy MACE or MASH: the PA form is NOT F-00163. It is Section VI of the PA/DGA form (F-11049). MACE and MASH PAs must be submitted via Portal, fax, or mail — not via the DAPO Center phone channel. The pharmacy provider, not the prescriber, submits the PA form to ForwardHealth.

If your PA is denied

A ForwardHealth PA denial (as distinct from a noncovered-service return) carries appeal rights through the Wisconsin fair-hearing process:

• Wisconsin Department of Administration, Division of Hearings and Appeals (DHA): PO Box 7875, Madison WI 53707-7875; fax 608-264-9885.
• Deadline: Request a fair hearing within 45 days of the action effective date. Late requests forfeit DHA jurisdiction.
• Because the pharmacy benefit is carved to ForwardHealth (not your HMO): you do NOT need to first exhaust your HMO’s Grievance and Appeal Committee process before requesting a DHA fair hearing for an AOM PA denial. The HMO grievance prerequisite applies only to medical-benefit denials, not pharmacy PA denials.
• Noncovered services (i.e., a PA request returned after the 2-lifetime-attempts cap is triggered): these are NOT subject to fair-hearing appeal. The program has classified these as noncovered services, and the DHA does not have jurisdiction over noncoverage determinations. A patient in this situation must pursue the special-indication pathways (MACE, MASH, OSA) or seek cash-pay options.

Related research

• North Carolina Medicaid GLP-1 coverage (2026): Pattern #9 — double reversal (covered → terminated → reinstated) — the closest positive-coverage analog: both NC and WI cover GLP-1s for chronic weight management at FDA-label-aligned BMI thresholds. The structural difference: NC has no published lifetime cap or BMI < 24 renewal-revocation rule; Wisconsin has both. NC’s coverage is politically contested (terminated October 2025, reinstated by gubernatorial directive December 2025); Wisconsin’s has been continuous since March 2023 with no termination event.
• Tennessee Medicaid (TennCare) GLP-1 coverage (2026): Pattern #13 — positive-coverage expansion via formal rulemaking — the third positive-coverage state alongside NC and WI. Tennessee expanded from a categorical-exclusion baseline effective August 1, 2025 via Sequence 10-34-25. TennCare publishes no lifetime cap and no BMI < 24 renewal-revocation rule. Wisconsin’s policy predates TennCare’s by approximately 27 months and uses an administrative PDL-review mechanism (not a formal rule) as its coverage instrument.
• GLP-1 pricing index: compounded vs. brand-name costs across 70+ telehealth providers — Wisconsin’s 2-lifetime-attempts cap creates a direct cash-pay funnel: a member who has exhausted both lifetime attempts for Wegovy or Zepbound under ForwardHealth has no further Medicaid coverage pathway for the chronic-weight-management indication. Understanding cash-pay pricing for compounded semaglutide and tirzepatide is the practical next step for members who have hit the cap.
• GLP-1 insurance-dropped coverage appeal playbook — four-phase appeal logic. Note: PA denials under ForwardHealth carry DHA fair-hearing rights (45-day deadline). Noncovered-service returns triggered by the 2-lifetime-attempts cap do NOT carry appeal rights — a Wisconsin-specific YMYL trap not covered by most generic appeal guides.
• 50-state Medicaid GLP-1 coverage tracker — full taxonomy of all 19 profiled states and their coverage pattern classifications, including the positive-coverage cluster (NC, TN, WI) and the explicit-exclusion cluster (TX, IL, IN, NJ, NY, AZ, PA).