Kansas Medicaid and GLP-1 coverage

The state's drug list carries an anti-obesity class and puts the newer drugs in it as preferred. Under "Anti-Obesity Medications," the preferred column lists "Wegovy (semaglutide) injection and tablets," "Wegovy HD (semaglutide) injection" and "Zepbound (tirzepatide) injection"; "Saxenda (liraglutide) injection" is non-preferred and requires prior authorization. The list's footer reads "Last Updated: 08/01/2026" and its header states "This PDL applies to drugs billed on the medical benefit and the pharmacy benefit."

Kansas Department of Health and Environment, Kansas Medicaid Preferred Drug List, effective August 2026 · source

Every GLP-1 in the class needs approval, and a whole other tier does not. The criteria document states "Prior authorization will be required for all current and future dose forms available" for liraglutide, semaglutide and tirzepatide, then adds in a footnote: "Benzphetamine, Diethylpropion, Phendimetrazine, Naltrexone/Bupropion, Orlistat, Phentermine, and Phentermine/Topiramate are covered products in this class, but do not require PA."

Kansas Department of Health and Environment, Anti-Obesity Medications prior authorization criteria · source

The entry test is a body mass index floor with a comorbidity alternative. "For Adults, must meet one of the following: BMI ≥ 30 kg/m2; BMI ≥ 27 kg/m2 AND has at least one weight-related comorbidity listed in Table 2." For patients 12 to under 18, the BMI "(standardized for age and sex) is in the 95th percentile or greater." The plan must also include "comprehensive adjunct lifestyle interventions (e.g., diet modification, physical activity, and behavioral therapy)." Age floors differ by drug: Saxenda and Wegovy from 12, Zepbound from 18.

Kansas Department of Health and Environment, Anti-Obesity Medications prior authorization criteria · source

Continuing is a two-stage test and the second stage is twice as demanding as the first. Kansas asks that "The patient has lost a total of 5% of pretreatment weight at 12 weeks and maintains the 5% weight loss," and then that "The patient has lost a total of 10% of pretreatment weight at 28 weeks and maintains the 10% weight loss." For adolescents the measure is a reduction in baseline BMI of more than 4 percent. First approvals run 28 weeks for Zepbound and Wegovy, and "LENGTH OF RENEWAL APPROVAL: 6 months for the first renewal, then 12 months thereafter."

Kansas Department of Health and Environment, Anti-Obesity Medications prior authorization criteria · source

Kansas set the policy on a dated bulletin and framed it around rebates rather than clinical criteria: "Effective with dates of service on and after September 19, 2023, coverage for anti-obesity medication (AOM) will include all AOMs that are rebate eligible."

Kansas Medical Assistance Program, KMAP General Bulletin 23255, October 2023, effective September 2023 · source

One list and one form govern every KanCare member. The state's anti-obesity prior authorization form is addressed jointly to four bodies in a single masthead — "Kansas Medical Assistance Program | Healthy Blue of Kansas | Sunflower | UnitedHealthcare" — and instructs the prescriber to "Complete form in its entirety and fax to the appropriate plan's PA department." The state's clinical prior authorization index likewise routes Saxenda, Wegovy and Zepbound to the same anti-obesity criteria "from the patient's specific health plan (MCO/FFS)."

Kansas Department of Health and Environment, Anti-Obesity Medications prior authorization form · source · clinical PA index

Kansas routes the first appeal to the plan, not the state, and gives 63 days. Its member page states that "the member or member's representative must submit a request for an appeal with the MCO within 63 calendar days from the date of the notice of the adverse benefit determination," and that KanCare members "must complete the appeal process with their managed care organization (MCO) prior to submitting a request for a state fair hearing." Keeping services running is a much shorter and differently-anchored clock: "you have 10 calendar days from the mailing date on the 'Notice of Adverse Benefit Determination Letter' to ask the MCO to continue your services during the appeal process." After the plan decides, a state fair hearing must be requested within 123 calendar days of that resolution notice.

Kansas Department of Health and Environment, KanCare — Appeals · source