Medicaid
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 35 or higher
- BMI of 30 or higher with a weight-related condition (heart failure with preserved ejection fraction, uncontrolled hypertension, CKD stage 3a or above, moderate or severe OSA, prediabetes (A1c >= 5.7% and < 6.5%) with documentation member is NOT a candidate for antidiabetic GLP-1, history of MI, history of stroke, symptomatic PAD, T2DM, and MASH with moderate to advanced liver fibrosis (F2 to F3))
Qualification pathways
You can qualify through any one of these.
Adult/Pediatric (age >=12) obesity – no comorbidities
All of:
- BMI >= 35 kg/m² prior to initiation of pharmacotherapy
Adult/Pediatric (age >=12) obesity – with qualifying comorbidity (BMI >= 30)
All of:
- BMI >= 30 kg/m² prior to initiation of pharmacotherapy
Plus any one of:
- Heart failure with preserved ejection fraction
- Uncontrolled hypertension
- Chronic kidney disease stage 3a or above
- Moderate or severe obstructive sleep apnea
Adult/Pediatric (age >=12) obesity – with qualifying comorbidity (BMI threshold not clearly specified in document)
All of:
- BMI >= [threshold not clearly printed in source document] kg/m² prior to initiation of pharmacotherapy
Plus any one of:
- Prediabetes (A1c >= 5.7% and < 6.5%) with documentation that member is NOT a candidate for antidiabetic GLP-1
- History of myocardial infarction
- History of stroke
- Symptomatic peripheral artery disease
- Type 2 diabetes mellitus
- MASH with moderate to advanced liver fibrosis (F2 to F3)
Documentation to bring
- Baseline BMI documentation
- Documentation of qualifying comorbidity if BMI < 35 kg/m²
- For prediabetes comorbidity: documentation of A1c >= 5.7% and < 6.5% AND documentation of why member is NOT a candidate for antidiabetic GLP-1
- For continuation: documentation of >= 5% weight loss from baseline OR documentation of established CVD OR documentation of improvement in OSA symptoms with AHI >= 15 and provider attestation OR documentation of improvement in secondary measures and provider attestation
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and At least one of: (1) weight loss >= 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation that improvement is related to anti-obesity therapy despite lack of weight reduction AND medical records documenting baseline or current AHI >= 15; (4) documentation of improvement in secondary measures (e.g., blood pressure, blood glucose) with attestation that improvements are related to anti-obesity therapy despite lack of weight reduction. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Policy note: The document appears to have a formatting gap: the BMI threshold for the third comorbidity tier is listed as 'BMI >= kg/m²' with the numeric value missing. The step-through phentermine requirement has been explicitly removed as of February 17, 2026. Criteria are shared with Zepbound for adult members for weight loss, CV risk reduction, and OSA indications. For pediatric members (age 12 to <18), a step through Wegovy was added for Saxenda, and pediatric criteria were added for Wegovy itself (age 12 to <18).
source: Pa policy