Keystone First does not cover Wegovy when it’s prescribed for weight loss. That exclusion took effect January 1, 2026, and applies across Keystone First’s Medicaid managed care and Community HealthChoices plans. Wegovy can still be covered, with prior authorization, when prescribed for certain other conditions such as reducing cardiovascular risk, moderate to severe sleep apnea, or a specific liver disease. Separate rules apply to members under 21 and to members of Keystone First VIP Choice, the plan’s Medicare Advantage product.
Why Weight Loss Is No Longer Covered
Keystone First follows the Pennsylvania Department of Human Services statewide Preferred Drug List. DHS ended Medicaid coverage of GLP-1 receptor agonists prescribed solely for overweight or obesity, and every prior authorization for that use expired on December 31, 2025. New requests have to be submitted under updated guidelines that no longer accept weight loss as a qualifying diagnosis.1Keystone First PA. PDL Notice – GLP-1 Receptor Agonists
When Keystone First Will Still Cover Wegovy
Wegovy remains available through Keystone First for several other FDA-approved or medically accepted uses, as long as the patient has a qualifying diagnosis beyond obesity itself and prior authorization is granted.2PA Department of Human Services. Medical Assistance Bulletin – GLP-1 Receptor Agonists
- Type 2 diabetes. GLP-1 drugs remain covered for diabetes management, with Wegovy as a non-preferred agent.3Keystone First PA. GLP-1 Receptor Agonists Prior Authorization Form
- Cardiovascular risk reduction. The FDA approved Wegovy in March 2024 to reduce the risk of heart attack, stroke, and cardiovascular death in adults with established heart disease and a BMI of 27 or higher. Keystone First will cover it for this use if the patient has a BMI of at least 27, documented cardiovascular disease such as a prior heart attack or stroke, optimized heart disease medications, and ongoing lifestyle modifications.4U.S. Food and Drug Administration. FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults With Obesity or Overweight3Keystone First PA. GLP-1 Receptor Agonists Prior Authorization Form
- Moderate to severe obstructive sleep apnea. Requires a BMI of at least 35, a confirmed OSA diagnosis, symptoms such as excessive daytime sleepiness, adherence to a CPAP machine or oral appliance, and a six-month trial of lifestyle changes unless there is a medical reason to start treatment sooner.3Keystone First PA. GLP-1 Receptor Agonists Prior Authorization Form
- Metabolic dysfunction-associated steatohepatitis (MASH). Requires moderate to advanced fibrosis (stage F2 or F3), no significant alcohol dependence, optimized treatment for other conditions, and documented lifestyle changes.3Keystone First PA. GLP-1 Receptor Agonists Prior Authorization Form
For every non-diabetes indication, Wegovy sits on the non-preferred tier. To get Wegovy specifically rather than a preferred GLP-1, the prescriber generally has to document that the patient tried and failed the maximum dose of Ozempic (which uses the same active ingredient, semaglutide) or has a clinical reason it can’t be used.2PA Department of Human Services. Medical Assistance Bulletin – GLP-1 Receptor Agonists
Members Under 21
The weight-loss exclusion does not apply to Keystone First members under 21. Under federal law, Medicaid must cover all medically necessary treatments for children and young adults through the Early and Periodic Screening, Diagnosis and Treatment program, and a plan cannot deny GLP-1 coverage for someone under 21 just because the prescription is for obesity or overweight. The plan has to evaluate medical necessity for that individual and explain any denial.5Pennsylvania Health Law Project. PA Medicaid Ends Adult Coverage of GLP-1s for Weight Loss6Pennsylvania Health Law Project. GLP-1 MA Coverage
A new prior authorization is still required for any fill with a start date on or after January 1, 2026. If a request is denied, the family can appeal, and filing within 15 days of the denial notice generally keeps coverage in place during the appeal.6Pennsylvania Health Law Project. GLP-1 MA Coverage
Keystone First VIP Choice and the Medicare GLP-1 Bridge
Keystone First VIP Choice is a Dual Eligible Special Needs Plan for members in the Philadelphia-area counties who have both Medicare and Medicaid.7Keystone First VIP Choice. Program Overview Standard Medicare Part D plans have historically not covered Wegovy for weight loss, though they may cover it for diabetes or cardiovascular disease.8Humana. Does Medicare Cover Weight Loss Drugs
Starting July 1, 2026, the Medicare GLP-1 Bridge program gives eligible Medicare beneficiaries access to Wegovy and certain other GLP-1 medications at a flat $50 for a one-month supply. The program is temporary, running through December 31, 2027.9Centers for Medicare & Medicaid Services. CMS to Provide $50 Monthly Access to GLP-1 Medications for Medicare Beneficiaries It’s open to members of Part D plans, including Medicare Advantage plans with drug coverage. A BMI of 35 or higher qualifies on its own; lower BMIs need a specific comorbidity such as a prior heart attack or stroke, prediabetes, or chronic kidney disease.10Medicare.gov. Weight Loss Drugs
Two limits are worth knowing. The $50 copayment doesn’t count toward the Part D deductible or out-of-pocket maximum. And people who already get GLP-1 drugs through their standard Part D plan, or who have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease, aren’t eligible for the Bridge because their standard plan may cover GLP-1s for those conditions instead.10Medicare.gov. Weight Loss Drugs
Other Weight-Loss Medications Still on the Formulary
The exclusion applies only to GLP-1 receptor agonists. Keystone First still covers other obesity treatment medications. Phentermine remains a preferred drug. Non-preferred options including phentermine-topiramate, diethylpropion, and orlistat are also covered but need prior authorization.11Keystone First PA. Supplemental Formulary The DHS Medical Assistance Bulletin confirmed that non-GLP-1 obesity treatment agents remain a covered benefit under the statewide Preferred Drug List.2PA Department of Human Services. Medical Assistance Bulletin – GLP-1 Receptor Agonists
For adults, the prior authorization form asks for a BMI of at least 30 (or at least 27 with a weight-related comorbidity), documentation of diet and exercise counseling, and, for non-preferred drugs, evidence of trying and failing preferred options first.12Keystone First PA. Obesity Treatment Agents Prior Authorization Form
If Your Request Is Denied
Members have two routes depending on the reason for the denial. A complaint is the right path if the denial is because the service isn’t a covered benefit; a grievance applies if the denial is based on medical necessity.13Keystone First PA. Complaints, Grievances, and Fair Hearings Process
- File within 60 days of the denial notice. Keystone First generally issues a decision within 30 days.
- File within 15 days if you want to keep getting the medication while the appeal is pending. Miss that window and coverage stops during the appeal.
- If the first-level decision goes against you, request an external review through the Pennsylvania Insurance Department within 15 days.
- You can also request a state fair hearing through the PA Department of Human Services within 120 days of the initial decision.
- If a doctor certifies that waiting could harm the patient’s health, an expedited review can be requested, with decisions typically made within 48 to 72 hours.
Keystone First’s appeals department can be reached at 1-800-521-6860 or by fax at 215-937-5367. Free legal help is available through the Pennsylvania Health Law Project at 1-800-274-3258.13Keystone First PA. Complaints, Grievances, and Fair Hearings Process