Delaware

Delaware finalized a State Plan change whose stated purpose is flexibility. The Division of Medicaid and Medical Assistance amended the Title XIX State Plan "to provide the state with increased flexibility to determine coverage of drugs for anorexia, weight loss, and weight gain without additional changes to the State Plan." The order explains that "The proposed change removes specific language about state coverage of weight loss drugs and replaces it with more general language that indicates that select agents for anorexia, weight loss, and weight gain will be covered as listed on the state's website." It gives the reason as well: "The category of drugs to treat weight conditions is undergoing rapid change."

Delaware Health and Social Services, Division of Medicaid and Medical Assistance, Final Order — Glucagon-Like Peptide-1 (GLP-1), 30 DE Reg. 149, effective September 2026 · source

The state says the change is not meant to alter coverage, and that sentence should be quoted rather than paraphrased: "This change is administrative in nature. It aligns the State Plan language with current coverage practice and is not intended to change which medications/agents/drugs are covered or the criteria for coverage."

Delaware Health and Social Services, Division of Medicaid and Medical Assistance, Final Order — Glucagon-Like Peptide-1 (GLP-1), 30 DE Reg. 149, effective September 2026 · source

The redline shows exactly which sentence went. On Attachment 3.1-A of the State Plan, the struck text reads "The State will cover drugs indicated for the treatment of obesity to address weight loss with co-morbid conditions with prior authorization." The text that replaces it reads "Select agents when used for weight loss and weight gain will be covered as listed on the state's website." A commitment stated in the State Plan became a pointer to a web page.

Delaware Medicaid State Plan, Attachment 3.1-A page 5, Limitations on Amount, Duration and Scope — Prescribed Drugs (amendment as adopted), effective January 2026 · source

What is covered today is a full weight-loss route, not just a non-weight-loss workaround. The state's prior authorization criteria grant coverage where the "For adult member – body mass index (BMI) ≥ 30 kg/m2", or where the "Member must be overweight as defined as a BMI between ≥ 27 kg/m2 and < 30 kg/m2 and have at least one (1) co-morbid condition listed below" — the listed conditions being cardiovascular disease, heart failure, chronic kidney disease stage 3a or above, hypertension, hyperlipidemia, peripheral artery disease, moderate to severe obstructive sleep apnea, and type 2 diabetes. The form is stamped "Revised: 4/20/2026".

Delaware Medical Assistance Program, Request for Medication Prior Authorization — GLP-1 Agonist for Weight Management, MASH or Prevention of MACE, effective April 2026 · source

The first approval is short and it is dispensed a month at a time. "Prior Authorization will be granted for up to 6 months in ≤ 30-day supplies, of an authorized GLP-1 agonist agent at a standard dose." Renewing turns on a measured result: "The minimum weight loss that must occur is ≥ 5% for adults and ≥ 4% for adolescents of the baseline weight."

Delaware Medical Assistance Program, Request for Medication Prior Authorization — GLP-1 Agonist for Weight Management, MASH or Prevention of MACE, effective April 2026 · source

The drug list has an obesity class of its own and puts the newer drugs at the top of it. Under "OBESITY TREATMENT AGENTS" the list states "Clinical criteria applies to class. All agents require a prior authorization." The preferred column holds Contrave ER, phentermine capsule and 37.5 mg tablet, Wegovy pen-injector, Wegovy HD pen-injector, Zepbound auto-injector and Zepbound KwikPen. Foundayo, Saxenda, Wegovy tablet, Xenical, orlistat, Lomaira, Adipex-P and the older stimulants are non-preferred, and the rule beside the class reads "Two (2) preferred products required before a non-preferred product will be approved." The edition is dated on its face: "Effective Date: 8/3/2026".

Delaware Medical Assistance Program, 2026 Delaware Medicaid Preferred Drug List, effective August 2026 · source

The state's own list warns that it does not describe most members. Its opening notes state that "any prior authorization criterion provided here is for FEE-FOR-SERVICE (FFS) MEMBERS ONLY" and that "Prior authorizations for members enrolled with a Managed Care Organization (MCO) should be processed through the MCO following MCO criteria", naming Highmark Health Options, AmeriHealth Caritas and Delaware First Health and linking each one's own criteria.

Delaware Medical Assistance Program, 2026 Delaware Medicaid Preferred Drug List, effective August 2026 · source

Delaware's hearing clock runs from when the action takes effect, not from the letter, and it cannot be extended. The rule states that "A hearing is granted if the request is received within 90 days from the effective date of action" and that "The hearing officer does not have authority to extend the time period beyond 90 days of the effective date of action." Managed care members have a different clock: a hearing is granted where the request arrives within "120 calendar days from the date of the MCO's notice of an appeal resolution". Filing inside the ten-day advance notice period is what keeps benefits running in the meantime.

Delaware Administrative Code, Title 16, DSSM 5000 — Fair Hearing Practice and Procedures · source