Pa. Medicaid Ends Adult Coverage of GLP-1s for Weight Loss
Effective January 1, 2026, Pennsylvania Medicaid will no longer cover GLP-1 medications when prescribed for weight loss for adults age 21 and over.
What Are GLP-1s?
GLP-1s are medications approved to treat several conditions, including weight loss, type 2 diabetes, and other health issues. Common brand names include Wegovy, Saxenda, Zepbound, Ozempic, Mounjaro, Victoza, and Trulicity.
What's Changing?
Pennsylvania Medicaid will stop covering GLP-1s for weight loss for adults 21 and older starting January 1, 2026.
Important: Everyone taking a GLP-1 must take action, even if this coverage change doesn't affect you. According to recent DHS guidance, anyone who wants to continue their GLP-1 past December 31, 2025 must have their doctor request a new authorization—including people under 21 and those taking GLP-1s for reasons other than weight loss.
Who Can Still Get GLP-1s After January 1?
1. Children and young adults under 21 may still receive GLP-1s for weight loss or to treat overweight/obesity. Federal law requires Medicaid to cover all medically necessary treatments for people under 21, even when those treatments aren't available to adults. This requirement is called Early and Periodic Screening, Diagnosis and Treatment (EPSDT).
2. Adults prescribed a GLP-1 for other conditions may still qualify if they meet prior authorization requirements. The FDA has approved certain GLP-1s to treat the following conditions in adults:
- Type 2 diabetes
- Obstructive sleep apnea in people with obesity
- Reducing the risk of serious cardiovascular events in people with overweight or obesity
- MASH, a serious liver disease
Remember: Children under 21 and adults must ask their doctors to submit a new prior authorization request before January 1, 2026 to avoid a gap in coverage.
What Should You Do Now?
Everyone taking a GLP-1 paid for by Medicaid has by now received a letter stating that coverage for their medication ends on December 31, 2025. This letter was sent regardless of age or reason for taking the medication.
If you are under 21 and take a GLP-1 for overweight/obesity, or if you take a GLP-1 for any condition other than adult weight loss, you should immediately:
- Appeal the letter by requesting a complaint or grievance through your Medicaid HealthChoices plan. Your plan cannot discourage or refuse to accept this request.
- Ask your doctor to submit a new prior authorization request with a start date of January 1, 2026. If this request is also denied, appeal that denial too.
Timing matters: If you request an appeal within 15 days of the date on the letter, your GLP-1 coverage should continue during the appeal process. If you appeal after that deadline but on or before December 31, 2025, coverage may or may not continue during the appeal. Appeal early and document when you submitted your request.
For People Under 21 Who Are Denied GLP-1s
If you are under age 21 and your Medicaid plan denies a GLP-1 saying the medication isn't covered for weight loss, appeal the denial. Under EPSDT, a Medicaid plan cannot simply say GLP-1s aren't covered for weight loss or obesity for people under 21. Instead, the plan must determine whether the GLP-1 is medically necessary to treat your condition and, if they decide the medication isn't medically necessary, they must explain why. If they haven't done this, you should appeal.
