Washington

Washington's noncovered-drugs regulation begins "The medicaid agency does not cover:" and lists, under drugs prescribed for a particular purpose, "For weight loss or gain." The current text was filed October 21, 2025 and took effect November 21, 2025. The same section says a noncovered drug can be requested through the exception-to-rule process, and the exception rule adds that a client has no right to a fair hearing on an exception-to-rule decision.

Washington State Legislature, WAC 182-530-2100 (Noncovered — outpatient drugs and pharmaceutical supplies), effective November 2025 · source

Wegovy's criteria say it in the first line of the weight-loss row: "Semaglutide injection or tablet (Wegovy®) is not covered by Apple Health for weight loss," citing WAC 182-530-2100. The document then lays out the two uses it will approve. For reducing cardiovascular risk you need a body mass index of 27 or more, to be 18 or older, to have no diabetes, and to have established cardiovascular disease from a named list; an approval runs 6 months and a renewal 12. There is also a pathway for a specific stage of liver disease. The revision history shows a December 1, 2025 change that "removed lifestyle requirements" and a February 1, 2026 change that added the Wegovy tablet.

Washington State Health Care Authority, Apple Health medical policy 61.25.20.AA-4 (Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists — Wegovy), effective February 2026 · source

Zepbound's criteria run only through sleep apnea. The weight-loss row reads "Tirzepatide (Zepbound®) is not covered by Apple Health for weight loss." The one approvable indication is moderate to severe obstructive sleep apnea in adults with obesity, and the list you have to meet includes being 18 or older, having no diabetes, a provider attestation of an AHI or RDI of 15 or more events per hour, a documented position on positive airway pressure therapy, being "engaged in lifestyle interventions including diet, exercise, and behavioral modification," and a body mass index over 30. Six months for an initial approval, twelve for a renewal. The policy is new as of May 1, 2025.

Washington State Health Care Authority, Apple Health medical policy 61.25.25.AA-1 (Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists — Zepbound), effective May 2025 · source

The preferred drug list says the same thing in its coding. Washington republishes the list every week; in the edition effective August 22 to August 28, 2026, the class headed "NEUROLOGICAL AGENTS : ANOREXIANTS / ANTI-OBESITY - GLP-1 RECEPTOR AGONISTS" carries 20 Wegovy rows and 32 Zepbound rows marked CP, a covered pharmacy benefit with prior authorization required, each tied to the policy number above. Saxenda sits in the same class marked NC with the reason code WGHT, which the list's own key defines as "Weight loss product." Contrave, Qsymia, phentermine and orlistat carry the same NC and WGHT flags. We checked the next week's edition too and every one of those statuses was unchanged.

Washington State Health Care Authority, Apple Health Preferred Drug List (weekly edition effective August 22, 2026), effective August 2026 · source

Your plan does not change the list. The Health Care Authority's drug list page says "All managed care plans and the fee-for-service program serving Apple Health clients use the Apple Health Preferred Drug List (PDL)," and a sentence later, "All plans will use the same PA criteria, step therapy edits, and quantity limits developed by HCA."

Washington State Health Care Authority, Apple Health Preferred Drug List page · source

If the decision came from the Health Care Authority itself rather than a plan, the statute gives you 90 calendar days: an applicant or recipient "must do so within 90 calendar days after receiving notice of the aggrieving decision unless good cause is shown." The agency's own hearing-rights notice puts it more plainly: "You have 90 days from the date at the top of the notice we mailed you to request a hearing," and to keep your current coverage while the hearing is decided "you must ask for a hearing within 10 days of receiving this notice or by the end of the month, whichever is later."

Washington State Legislature, RCW 74.09.741(4); Washington State Health Care Authority, form HCA 12-506 (hearing rights notice) · source

If you're in a managed care plan, and most people are, the route is different and the plan comes first. The managed care rule says "an enrollee must file an appeal within 60 calendar days of the date on the MCO's notice of adverse benefit determination," and under its heading "Deadline – 120 days," that a request for a state hearing "must be filed no later than 120 calendar days from the date of the written notice of resolution of appeal from the MCO." The hearing rules confirm the order: "An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing with HCA." To keep the drug meanwhile, the appeal has to be filed within 10 calendar days of the plan mailing its notice, or by the effective date of the action, whichever is later. This version of the managed care rule took effect March 17, 2025.

Washington State Legislature, WAC 182-538-110 (managed care grievance and appeal system) and WAC 182-526-0200 (hearing requests by MCO enrollees), effective March 2025 · source

We looked for a provider alert announcing any of the changes above. The Health Care Authority's alert pages for 2025 and 2026 link 43 and 24 alerts; we read all 67 titles and none mentions GLP-1s, obesity, weight, Wegovy or Zepbound. The only dated change records we could find are the revision-history tables printed inside the three criteria documents themselves, so the dates on this page come from those tables and not from an announcement.

Washington State Health Care Authority, Provider alerts (2025 and 2026 listings) · source