The use of GLP-1 (glucagon-like peptide-1) drugs has revolutionized the treatment of type 2 diabetes for over a decade, and newer forms have gained attention for their effectiveness in treating obesity. While these drugs offer new possibilities for obesity treatment, they also raise questions about access and affordability. Zepbound, a medication approved by the Food and Drug Administration (FDA) for weight loss management and the treatment of moderate to severe obstructive sleep apnea (OSA) in individuals with obesity, is one such drug. This article aims to provide a comprehensive overview of Medicaid coverage for Zepbound, including current policies, potential changes, and strategies for accessing the medication.
Current Landscape of Medicaid Coverage for Obesity Drugs
States have the option to cover obesity drugs under Medicaid. Under the Medicaid Drug Rebate Program (MDRP), Medicaid programs must cover almost all FDA-approved drugs from participating manufacturers for medically accepted indications. However, weight-loss drugs like Zepbound, Ozempic, and Wegovy are among a small group of drugs that can be excluded from coverage.
As of August 2024, 13 state Medicaid programs covered GLP-1s for obesity treatment. Twelve states in KFF’s annual budget survey reported coverage of GLP-1s for obesity treatment under Fee-For-Service (FFS) as of July 1, 2024, and North Carolina reported adding coverage in August of 2024. All 12 states that reported coverage of GLP-1s as of July 1, 2024 also reported that utilization control(s) applied, with the most common being prior authorization (11 of 12 states) and/or BMI requirements (11 of 12 states). Eleven of the 12 states reported covering all three GLP-1s currently approved for the treatment of obesity (Saxenda, Wegovy, or Zepbound).
While the survey only asked about FFS coverage, Managed Care Organization (MCO) drug coverage must be consistent with the amount, duration, and scope of FFS coverage. MCOs, however, may apply differing utilization controls and medical necessity criteria unless the state’s MCO contract specifies otherwise.
Coverage among other payers also remains limited.
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The Rising Cost and Utilization of GLP-1s
The number of Medicaid prescriptions and gross spending on GLP-1s have increased rapidly in recent years, with both nearly doubling from 2022 to 2023. Overall, from 2019 to 2023, the number of GLP-1 prescriptions increased by more than 400%, while gross spending increased by over 500%. Spending per prescription before rebates reached more than $900 per prescription in 2023.
Those prices and spending numbers do not account for rebates, and states are likely receiving substantial rebates on these brand drugs. While rebate data for specific drugs is not publicly available, Medicaid and CHIP Payment and Access Commission (MACPAC) analysis of FY 2020 data found statutory rebates accounted for 61.6% of gross Medicaid spending on brand drugs. Also, amid growing criticism of the cost of their drugs, Novo Nordisk, the company that creates Ozempic and Wegovy, has said that rebates and other fees (across all payers) account for about 40% of the cost of the two drugs.
The GLP-1s in this analysis still account for relatively small shares of the total number of Medicaid prescriptions and spending before rebates, though the shares are growing. Specifically, increased utilization of Ozempic, Wegovy, and Mounjaro have contributed substantially to recent growth. Prescriptions and spending on Ozempic, approved to help control blood sugar levels for adults with type 2 diabetes in 2017, have grown considerably from 2019 to 2023, nearly doubling every year since 2019. Looking from 2022 to 2023, the latest year of data available, Wegovy (first approved in 2021) and Mounjaro (approved in 2022) also saw substantial growth, with prescriptions and gross spending for both drugs increasing twelvefold or more.
From Medicaid data publicly available, there is no way yet to disentangle how much of the growing use of GLP-1s is related to treatment for diabetes versus obesity, or a combination of both. In addition, the popularity and increased demand for GLP-1s has led to drug shortages, sometimes causing people to switch products or ration doses or sometimes leaving individuals without access to needed prescriptions.
North Carolina Medicaid's Decision to Discontinue Coverage
According to the NC Medicaid Division of Health Benefits, certain weight loss medications will be discontinued due to insufficient program funding. Those medications include Wegovy, Zepbound and Saxenda. Coverage for GLP-1 medications used to treat diabetes will remain unchanged.
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Specifically, effective Oct. 1, 2025, NC Medicaid coverage for GLP-1s for the treatment of obesity, which is an optional benefit for Medicaid programs, will be discontinued. 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).
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.
- Wegovy: To reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease who are obese; 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: To treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
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.
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Accessing Zepbound: Prior Authorization and Step Therapy
According to Annie DePasquale, MD, a board-certified family medicine physician and founder and CEO of Collaborating Docs in Arlington, Virginia, coverage for Zepbound varies by state and plan. “Many Medicaid programs now cover at least some anti-obesity medications-but rules vary widely,” she explains.
Prior authorization, also known as prior approval, pre-authorization, or pre-certification, is a standard health insurance process that helps insurers ensure that the prescribed treatments are medically necessary for beneficiaries. In most cases, your healthcare provider who wants to prescribe Zepbound is responsible for starting the prior authorization request by submitting a medical necessity letter.
Step therapy, also known as “fail first,” or step protocol, is a process in which insurers require you and your healthcare provider to take specific steps before they’ll cover or pay for your medication. You may have to try alternative, lower-cost medications to treat your medical conditions before moving to a more expensive drug like Zepbound. Step therapy for Zepbound could involve a trial of a formulary anti-obesity drug, such as naltrexone/bupropion (brand names Revia/Wellbutrin) or phentermine/topiramate (brand names Adipex/Topamax), as long as they’re not contraindicated or clinically inappropriate, Dr.
A potential downside to step therapy is that by requiring you to try less expensive drugs, it may disrupt your care, especially if your healthcare provider recommends a medication like Zepbound that isn’t the insurer’s preferred treatment.
If approved through prior authorization or after completing step therapy, your healthcare provider can proceed with prescribing Zepbound, and you can then collect it from your pharmacy. “If denied, appeal with any missing documentation (sleep study, cardiometabolic risk notes, dietitian visits),” Dr. DePasquale says.
A peer-to-peer (P2P) review in insurance is a telephone call between a healthcare provider and an insurance company physician to discuss a claim or prior authorization that has been denied or will be denied for medical necessity reasons.
Navigating Denials and Appealing Decisions
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. If Medicaid plans deny a Zepbound prescription, you and your healthcare provider can appeal through processes like prior authorization and step therapy.
Cost-Saving Strategies
If Medicaid does not approve your healthcare provider’s requested prescription for Zepbound, you may need to pay for the weight loss drug out of pocket. If your insurance plan approves Zepbound, copays or coinsurance will vary depending on your state’s Medicaid program. “Patients should defer to their treating clinician and, when applicable, their plan’s care manager for the most up-to-date guidance,” Dr.
Different pharmacies offer different prices for the same medication. One method to reduce your costs is to visit the prescription medication’s coupon page on SingleCare to obtain it at a discounted price of $950 for 4, 5 mg/0.5 mL pens. To get started, you’ll want to visit Zepbound’s coupon page and choose the best coupon for you at your preferred pharmacy. From there, you’ll have the option to print your coupon or download it to your mobile device.
In Dr. DePasquale’s experience, she has seen her Medicaid patients pay out-of-pocket for medications like Zepbound and has witnessed how a combination of medical treatment and lifestyle changes has led to weight loss and significant improvements in blood pressure and blood sugar levels.
Medicaid Coverage for Dual Eligibles
Medicaid consumers in Pennsylvania 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 (described below). 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.
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).
The Future of Medicaid Coverage for Obesity Drugs
Many state Medicaid programs are considering covering obesity drugs in the future but are concerned about the cost implications. KFF’s annual budget survey found that, among those states that do not currently cover obesity drugs, half reported they were considering adding coverage, with a few states reporting plans to add or expand coverage in FY 2025 or later.
When asked about the key factors contributing to their obesity medication coverage decision, almost two-thirds of responding states mentioned cost, though states are also weighing a number of other factors including the need for legislative action, adherence concerns, clinical criteria development, and potential side effects. Conversely, 4 in 10 states noted that positive health outcomes and longer-term savings on chronic diseases associated with obesity were key factors in their decision to cover or consider covering in the future along with increasing enrollee access and health equity, recommendations from providers, and ability to negotiate supplemental rebate agreements.
States are likely considering various cost containment strategies for these drugs and may even be re-evaluating their broader approach to obesity treatment, including the use of obesity medications along with other treatments such as nutritional counseling or behavioral therapy.