The question of whether Medicaid covers weight loss medications, particularly GLP-1s (glucagon-like peptide-1 receptor agonists), is complex and varies significantly by state. While these medications have shown promise in treating obesity and related conditions, coverage decisions are influenced by factors such as state funding, clinical criteria, and federal regulations. This article explores the current landscape of Medicaid coverage for weight loss drugs, focusing on specific state policies, recent changes, and the broader implications for beneficiaries and healthcare systems.
Current State of Medicaid Coverage for Weight Loss Medications
Medicaid programs are administered at the state level, resulting in diverse coverage policies for weight loss medications. As of late 2023, a limited number of states offered Medicaid coverage for GLP-1s specifically for obesity treatment. North Carolina initiated coverage for certain FDA-approved GLP-1s for obesity within specific populations in August 2023, followed by South Carolina in November 2023.
Pennsylvania
Medicaid consumers in Pennsylvania who are prescribed medication for the treatment of obesity may be able to get these medications covered if they meet certain criteria. Medicaid coverage of these weight loss drugs is available to participants who meet the prior authorization criteria. Importantly, this includes people who have both Medicaid and Medicare, known as “dual eligibles”. Typically, Medicaid does not provide drug coverage for dual eligibles. Dual eligibles must get their medications covered through Medicare Part D (Medicare’s prescription drug benefit). However, Medicaid can cover certain medications excluded from the Medicare Part D benefit. Medicare Part D coverage rules specifically exclude coverage of prescription medications used solely for weight loss. Another example of excluded Part D drugs that are covered by Medicaid for dual eligibles are over-the-counter medications. All three weight loss medications for obesity treatment are in a class of drugs (called GLP-1 receptor agonists) that have been used to treat diabetes for several years. Each of the newer weight loss drugs now on the Medicaid preferred drug list has a version of the medication used for diabetes treatment. In order for Medicaid to cover these new weight loss drugs, a person’s doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, to get these drugs covered, adults over age 18 must have a body mass index (BMI) of 30 or higher (or 27 or higher with certain additional requirements), and they must have at least one weight-related health condition. People who have diabetes or have used a diabetes drug in the previous 120 days have an additional requirement: they must try and fail treatment on one of the preferred diabetes treatment versions of the weight loss drugs, or another preferred diabetes drug in the same drug class (GLP-1 receptor agonists). The requirement to try and fail on one of the diabetes treatment drugs likely means people on both Medicare and Medicaid who have diabetes who are prescribed one of the above medications for obesity treatment/weight loss will need to seek coverage of a diabetes version of a weight loss drug through their Medicare Advantage Plan or Medicare Part D drug plan. Medicare plans do cover the diabetes drugs that have a weight loss version but may not cover all of these medications on their formulary (list of covered drugs). People have a right to appeal if Medicaid denies coverage for the new weight loss drugs after a doctor submits the prior authorization showing the patient meets the criteria.
North Carolina's Evolving Policy
Last August, North Carolina began covering some federal Food and Drug Administration-approved GLP-1s for obesity treatment among some populations. Kody Kinsley, former secretary of the North Carolina Department of Health and Human Services, emphasized the importance of covering these medications, citing both ethical considerations and potential long-term cost savings. The department estimated the annual cost of covering GLP-1s under the new policy to be approximately $16 million.
However, due to shortfalls in state funding, NC Medicaid coverage for GLP-1s for the treatment of obesity will be discontinued effective Oct. 1, 2025. NC Medicaid remains committed to the potential of GLP-1s for the treatment of obesity; however, at this time the lack of funding for the program prohibits continued coverage for weight management purposes. GLP-1s will continue to be covered for the indications of diabetes, reduction in cardiovascular death, heart attack and stroke in obese adults with cardiovascular disease, noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) and severe obstructive sleep apnea (OSA).
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Effective Oct. 1, 2025, Wegovy, Zepbound and Saxenda will be removed from the Preferred Drug List (PDL) as an off-cycle change. Saxenda will no longer be covered for any indication. The Non-Incretin Mimetics class of drugs for treatment of obesity will continue to be managed through the PDL. Drugs in the Preferred status on the PDL include: diethylpropion, phendimetrazine and phentermine. These products do not require prior approval. Coverage of Wegovy and Zepbound will be managed through prior authorization, using clinical criteria established by the State for the below Food and Drug Administration (FDA) approved indications.
Continued Coverage for Other Indications
Wegovy will continue to be covered to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease who are obese and for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults. Zepbound will continue to be covered to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Prior Authorization Requirements
Providers will need to obtain a new prior authorization for beneficiaries receiving Wegovy and Zepbound, effective Oct. 1, 2025. Current prior authorizations will no longer be valid after Sept. 30, 2025. Prior authorization requests can be submitted beginning Oct. 1, 2025. There will be no changes to coverage for GLP-1 medications for the treatment of diabetes. Additionally, Weight Management (Non-Incretin Mimetics) will still be covered as listed on the PDL.
Access Challenges and Individual Stories
In Arizona, as in most states, Medicaid often does not cover GLP-1s for obesity alone. Jesse, a 32-year-old from Glendale, was only able to access Trulicity after being diagnosed with Type 2 diabetes. While the medication helped him lose weight and manage his blood sugar, his initial struggles highlight the challenges faced by individuals who need these medications for weight loss but do not meet the criteria for diabetes treatment.
Angela Rich, who has lipedema, encountered a dead end when her doctor prescribed Wegovy, illustrating the difficulties in obtaining coverage even when there is a clear medical need.
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The Role of Prior Authorization
In order for Medicaid to cover these new weight loss drugs, a person’s doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, to get these drugs covered, adults over age 18 must have a body mass index (BMI) of 30 or higher (or 27 or higher with certain additional requirements), and they must have at least one weight-related health condition. People who have diabetes or have used a diabetes drug in the previous 120 days have an additional requirement: they must try and fail treatment on one of the preferred diabetes treatment versions of the weight loss drugs, or another preferred diabetes drug in the same drug class (GLP-1 receptor agonists).
Financial Implications and Cost Considerations
The increasing demand for GLP-1 drugs has led to significant increases in Medicaid spending. According to KFF, Medicaid spending on GLP-1s for all conditions rose from $597.3 million for approximately 755,000 prescriptions in 2019 to $3.9 billion for 3.8 million prescriptions in 2023. It’s hard to tell, however, how much of the increase is solely for obesity vs. other conditions, such as diabetes.
The Congressional Budget Office (CBO) analyzed the potential impact of covering anti-obesity medications, acknowledging the rapid evolution of clinical data and the difficulty of assessing whether weight loss alone would reverse weight-related chronic conditions and lead to cost savings. In January, state Rep. If 75% of them took advantage of the coverage, the committee estimated, the annual cost to state taxpayers would range from $192 million to $496 million.
Balancing Costs and Benefits
While the upfront costs of covering GLP-1s may seem high, proponents argue that these medications can lead to long-term cost savings by preventing or managing obesity-related comorbidities such as diabetes, heart disease, and other conditions.
“Clearly, that’s a system where the people who are wealthier and can afford that will end up getting the medication and other people will not,” said Dr. Carol Olson, a psychiatrist at Valleywise Health in Maricopa County.
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Kinsley noted that Medicaid covers other expensive drugs and that funding drugs that can cut costs down by even a small percentage is worthwhile in the long run.
Federal Initiatives and Policy Debates
At the federal level, there are ongoing discussions about expanding coverage for weight loss medications under both Medicaid and Medicare. Since 2003, Congress has prohibited GLP-1 coverage for weight loss alone under Medicare, the federal program for retirees and people with disabilities.
Proposed Rule by the Biden Administration
In late November, the Biden administration proposed a new rule to require Medicaid and Medicare programs to cover GLP-1s for weight loss. The Biden administration estimates that the change would cost the federal government about $11 billion over the course of 10 years for Medicaid.
Congressional Interest and HHS Stance
ACG expects continued interest in GLP-1 medications from both the administration and Congress. To date, HHS leadership have sent mixed signals on the issue. HHS Secretary Robert F. In addition, the United States Preventive Services Task Force (USPSTF) is developing a draft recommendation statement on whether weight-loss interventions affect health outcomes such as cardiovascular disease.
Challenges and Considerations
Several factors complicate the decision of whether to cover weight loss medications under Medicaid. These include:
Equity Concerns
Ensuring equitable access to weight loss medications is a key consideration. Dr. Carol Olson noted the potential for disparities if only wealthier individuals can afford these treatments.
Clinical Effectiveness and Patient Selection
GLP-1s are not the answer for everybody,” Ro told Stateline. A healthy weight is a BMI of up to 25. “You shouldn’t expect to see almost any cost savings for somebody whose BMI is around 30 or 31,” Cawley told Stateline.
Socioeconomic Factors
Residents struggle with losing weight not only due to a diet of unhealthy foods, but also because of generational genetics, a dearth of grocery stores with healthy foods, and busy schedules with multiple jobs and a lack of child care. And some of the state’s most popular foods are high-fat, high-sugar dishes such as pork shoulder slathered in sugary and smoky barbecue sauce, peach cobbler, fried shrimp and fried green tomatoes. There, 70% of residents are either overweight or obese. Obesity is linked to several comorbidities, such as diabetes and heart failure. That rate rises across demographic groups.