Medicaid GLP-1 coverage for weight loss is a state option: each state decides whether its Medicaid program pays for drugs such as Wegovy, Zepbound and Foundayo when they are prescribed for obesity [1][3].
At a glance
10 of 51 Medicaid programs covered a GLP-1 for weight loss as of Oct 18, 2026; 32 do not and 2 are not confirmed.
Medicaid GLP-1 coverage by state, Oct 18, 2026Federal law lets states exclude drugs used for weight loss, but not the heart, sleep apnea or diabetes uses [1][3].
Why most states can say noSeven programs ended weight-loss coverage in 2026, most recently Rhode Island on Oct 1 [91].
What changed in 2025 and 2026As of late August 2026, Indiana was the only state to say publicly it is joining the BALANCE model [132].
The CMS BALANCE modelWithout coverage, self-pay Zepbound starts at $299 a month and Wegovy pens cost $349 a month at standard doses, checked Oct 17, 2026 [135][134].
If your state does not cover it
Medicaid GLP-1 coverage by state, Oct 18, 2026
Each row is one Medicaid program. “Weight loss coverage” is about obesity treatment only. The heart risk and sleep apnea columns are separate uses with separate rules, so a state can say no to weight loss and still pay for Wegovy after a heart attack or Zepbound for sleep apnea. PA means prior authorization. “Via weight-loss PA” means the condition counts toward the state's weight-loss criteria instead of having its own pathway. What each status means is under How we check.
| Status | Programs | Which ones | Medicaid and CHIP enrollment, June 2026 |
|---|---|---|---|
| Covered | 7 | Delaware, Kansas, Minnesota, Mississippi, Missouri, North Carolina and Tennessee | 7,779,856 |
| Covered with limits | 3 | Michigan, Virginia and Wisconsin | 4,872,732 |
| Ended in 2026 | 7 | California, Massachusetts, New Hampshire, Pennsylvania, Rhode Island, South Carolina and Utah | 17,868,987 |
| Not covered | 32 | 32 states (see the full table) | 42,101,584 |
| Not confirmed | 2 | District of Columbia and Idaho | 544,230 |
| All programs | 51 | 50 states and DC | 73,167,389 |
| State | Weight loss coverage | Drugs and rules | Wegovy for heart risk | Zepbound for sleep apnea | Latest change |
|---|---|---|---|---|---|
| Alabama | Not covered | PDL footnotes exclude Wegovy for weight reduction and Zepbound for weight reduction without sleep apnea, per a secondary reading of the July 2026 PDL. HJR162 (Mar 5, 2026) asks Medicaid to study the cost of coverage. [5][6][7] | Not confirmed | Covered with PA (secondary source) | Mar 5, 2026: Legislature asks Medicaid to study GLP-1 costs (HJR162) |
| Alaska | Not covered | Weight control is excluded by regulation (7 AAC 105.110 and 7 AAC 120.112). Wegovy needs BMI 25 or more with heart disease or MASH; Zepbound needs BMI 30 or more with sleep apnea. [8][9] | Covered with PA | Covered with PA | Sep 18, 2026: semaglutide and tirzepatide criteria updated (Version 2) |
| Arizona | Not covered | AHCCCS policy AMPM 310-V lists medications used for weight loss as a pharmacy benefit exclusion, for managed care plans and fee-for-service. [10] | Not confirmed | Not confirmed | No 2025 or 2026 change found |
| Arkansas | Not covered | The pharmacy program states it does not cover medications for weight loss (DUR memo, May 13, 2026). Wegovy is covered for heart risk and MASH; Zepbound for sleep apnea only. [11][12][145] | Covered with PA | Covered with PA (OSA only) | Apr 15, 2026: Wegovy tablets added to the heart-risk criteria |
| California | Ended in 2026 | Adult weight-loss coverage ended Jan 1, 2026 under the 2025-26 Budget Act, in fee-for-service and all managed care plans. Members under 21 are reviewed under EPSDT. Zepbound and Saxenda were removed from the drug list. [13][14][15][144] | Covered with PA (medical necessity review) | Covered with PA | Apr 1, 2026: Wegovy for MASH no longer needs PA (weight-loss coverage ended Jan 1, 2026) |
| Colorado | Not covered | Appendix P (Oct 1, 2026) states that medications prescribed for weight loss are not a covered benefit. [16] | Not confirmed | Not confirmed | No 2025 or 2026 change found |
| Connecticut | Not covered | No GLP-1s for weight loss. Since June 1, 2025 the state plan (SPA 25-0014) covers only orlistat and phentermine for weight loss. Wegovy is not covered for weight management alone. [17][18][19] | Covered with PA | Covered with PA (since Jul 1, 2025) | Nov 3, 2025: Wegovy added for MASH; Wegovy claims need a heart or MASH diagnosis |
| Delaware | Covered | Wegovy, Zepbound, Saxenda and liraglutide with PA: BMI 30 or more, or 27 to under 30 with a weight-related condition, plus diet and activity. Renewal needs 5% weight loss. [20][21] | Covered with PA | Via weight-loss PA | Apr 20, 2026: state PA form revised (weight management, MASH and heart risk) |
| District of Columbia | Not confirmed | Fee-for-service excludes anti-obesity drugs (2023 provider manual), but MedStar Family Choice DC, one of two managed care plans, lists Wegovy and Zepbound with PA; the uses it approves were not found. [22][23][24] | Not confirmed | Not confirmed | Aug 1, 2026: Wellpoint DC members moved to AmeriHealth Caritas DC |
| Florida | Not covered | Weight control medications are a non-covered category. Heart and sleep apnea cells are per one managed care plan's policy (Aetna Better Health of Florida, Sep 1, 2026); AHCA criteria for those uses were not found. [25][26][27] | Covered with PA (per one managed care plan's policy) | Covered with PA (per one managed care plan's policy) | Aug 2026: Florida declined the BALANCE model |
| Georgia | Not covered | No adult GLP-1 weight-loss coverage. Saxenda and Xenical are listed only for ages 12 to 17 (PDL Oct 1, 2026). [28][29] | Not confirmed | Not confirmed | Jan 1, 2026: weight management class reviewed, no changes |
| Hawaii | Not covered | Plan by plan. The findings in a 2026 Senate bill say the state excludes GLP-1s for obesity in most situations, and the AlohaCare and UnitedHealthcare QUEST plans exclude weight-loss drugs; the other three plans were not checked. 2026 bills to lift the exclusion failed. [30][31][32][146][147] | Not confirmed | Not confirmed | 2026 session: bills to require coverage (SB 3195, HB 2456) failed |
| Idaho | Not confirmed | The PDL (July 1, 2026) has no weight-loss class and no Wegovy or Zepbound rows, and GLP-1s need a type 2 diabetes diagnosis. No written weight-loss exclusion was found in rule IDAPA 16.03.09.662. [33][34] | Not confirmed | Not confirmed | No 2025 or 2026 change found |
| Illinois | Not covered | Wegovy and Zepbound are not covered for weight loss alone (PDL Oct 1, 2026). [35] | Covered with PA (heart risk and MASH only) | Covered with PA (OSA only) | No 2025 or 2026 change found |
| Indiana | Not covered | Wegovy and Zepbound are not covered exclusively for weight loss (PA criteria Dec 1, 2025). On Jul 30, 2026 the governor said Medicaid will cover select GLP-1s for obesity through the BALANCE model; start date and criteria were not announced as of Aug 10, 2026. [36][37][38] | Covered with PA (age 45+, BMI 27+) | Covered with PA (BMI 30+) | Jul 30, 2026: joining the BALANCE model announced |
| Iowa | Not covered | Weight loss is an excluded use under the Iowa State Plan (PA form 470-0058, January 2026). [39] | Covered with PA (BMI 27+) | Covered with PA (BMI 30+) | No 2025 or 2026 change found |
| Kansas | Covered | Wegovy, Zepbound, Saxenda and Foundayo with PA: BMI 30 or more, or 27 with a weight-related condition, plus a lifestyle plan. A stricter high-cost rule (BMI 40 and 3 months of lifestyle change) does not apply to Zepbound (since Apr 1, 2024) or Wegovy (since Jun 1, 2025) but still lists Saxenda and Foundayo. Criteria reviewed Aug 19, 2026. [40][41] | Covered with PA (BMI 27+) | Via weight-loss PA | Jun 1, 2025: Wegovy exempted from the high-cost BMI 40 rule |
| Kentucky | Not covered | Regulation 907 KAR 23:010 excludes drugs used for weight loss unless the outpatient drug list covers them, and the Wegovy criteria list only heart risk and MASH. [42][43][44] | Covered with PA (age 45+, BMI 27+) | Covered with PA (after a 3-month PAP trial, unless PAP is not tolerated or contraindicated) | No 2025 or 2026 change found |
| Louisiana | Not covered | No general obesity coverage today. Act 898 of 2026 (SB 433) requires coverage of FDA-approved weight-loss drugs from Jan 1, 2027, with criteria set by LDH, subject to appropriation. [45][46][47][126] | Covered with PA (age 45+, BMI 27+) | Covered with PA (BMI 30+) | Jun 9, 2026: Act 898 signed; coverage due Jan 1, 2027 |
| Maine | Not covered | MaineCare policy does not allow coverage for weight-loss products. LD 480, a bill to add coverage, died in 2025. [48][49][50] | Covered with PA (BMI over 27) | Covered with PA (non-preferred) | Mar 11, 2025: DUR Board added Zepbound for sleep apnea |
| Maryland | Not covered | COMAR 10.09.03.05 excludes agents used for weight control. The fee-for-service PDL (July 1, 2026) lists no Wegovy, Zepbound or Foundayo; managed care formularies were not checked. [51][52][53] | Covered with PA (BMI 27+) | Covered with PA (BMI 30+) | May 2026: draft state drug board paper recommends joining BALANCE |
| Massachusetts | Ended in 2026 | Weight-loss coverage ended July 3, 2026 per MassHealth (news reports said July 1), in every plan type. Remaining uses need PA and Wegovy is the sole preferred drug. Members under 21 are reviewed under EPSDT. [54][55] | Covered with PA (BMI over 27) | Covered with PA, after a Wegovy trial | Jul 3, 2026: weight-loss coverage ended |
| Michigan | Covered with limits | Since Jan 1, 2026: BMI 40 or more, trial of five older weight-loss drug types, and only to avoid bariatric surgery. Wegovy, Zepbound and Saxenda with PA; renewal needs 5% loss. [56][57][58] | Covered with PA | Covered with PA | Jan 1, 2026: limited to BMI 40 or more; Nov 1, 2026 (scheduled): Foundayo added |
| Minnesota | Covered | The Jan 2026 PDL lists Wegovy, Saxenda and Zepbound as weight management drugs, with Wegovy and Saxenda shown as preferred and Zepbound as non-preferred; PA applies. The current BMI and renewal rules on the state PA page could not be read; that page changed Aug 4, 2026. [59][60][61] | Not confirmed | Not confirmed | Mar 25, 2026: bill to end coverage (HF4142) laid over |
| Mississippi | Covered | Wegovy, Zepbound, Saxenda and Foundayo preferred with PA: BMI 30 or more, or 27 to 29 with a weight-related condition. Renewal needs 5% loss. Since July 2026 adult claims with an obesity code can be approved electronically. [62][63] | Via weight-loss PA | Via weight-loss PA | Jul 1, 2026: criteria list Foundayo; electronic approval for adults |
| Missouri | Covered | Zepbound preferred with PA: BMI 30 or more, or 27 with a weight-related condition; ages 12 to 17 by BMI percentile. Wegovy is not covered for weight loss. Coverage began Jan 9, 2025. [64][65] | Covered with PA (age 45+, BMI 27+) | Via weight-loss PA | Oct 14, 2025: obesity criteria revision proposed; PA form dated Jan 2026 |
| Montana | Not covered | Drugs used for weight loss are listed as non-covered. [66][67] | Covered with PA | Covered with PA (AHI 15+ while on PAP) | No 2025 or 2026 change found |
| Nebraska | Not covered | DHHS excludes drugs prescribed for weight control or appetite suppression. The sleep apnea cell is per one managed care plan's policy (Nebraska Total Care); the state form was not opened. [68][69][70] | Covered with PA (ages 45 to 74) | Covered with PA (per one managed care plan's policy) | No 2025 or 2026 change found |
| Nevada | Not covered | The Medicaid Services Manual excludes agents used for weight management, per a secondary reading (the manual itself could not be opened). [5][71][72] | Covered with PA | Not confirmed | Jan 5, 2026: Wegovy criteria added for MASH |
| New Hampshire | Ended in 2026 | No coverage when prescribed solely for weight loss since Jan 1, 2026 (provider notice Oct 9, 2025), naming Saxenda, Wegovy and Zepbound. [73][3] | Covered (PA rules not reviewed) | Covered for severe OSA (PA rules not reviewed) | Jan 1, 2026: weight-loss coverage ended |
| New Jersey | Not covered | N.J.A.C. 10:51-1.13 excludes antiobesity agents when used for obesity, except lipase inhibitors such as orlistat. [74][75] | Covered (criteria not reviewed) | Covered (criteria not reviewed) | No 2025 or 2026 change found |
| New Mexico | Not covered | The Health Care Authority lists Saxenda, Wegovy and Zepbound as not covered for weight reduction. [76][3] | Not confirmed | Not confirmed | No 2025 or 2026 change found |
| New York | Not covered | NYRx excludes drugs used for weight loss under SSA 1927(d)(2) (pharmacy manual, September 2026). The heart-risk rule asks for BMI over 40, far above the FDA label. [77][78] | Covered with PA (BMI over 40) | Not confirmed | Jul 23, 2026: Wegovy coverage overview revised |
| North Carolina | Covered | Restored Dec 12, 2025 under the criteria in place Sep 30, 2025: prior approval, BMI 30 or more, or 27 with a weight-related condition, plus lifestyle changes; renewal needs 5% loss. Wegovy preferred, Zepbound and Saxenda non-preferred at reinstatement. Sources disagree on October 2026: one managed care plan lists Zepbound and Foundayo as preferred from Oct 1, 2026, while the state drug list notes the Zepbound vial was removed from the obesity class Sep 4, 2026. Coverage had ended Oct 1, 2025. [79][80][81][142][143] | Covered with PA | Covered with PA | Dec 12, 2025: coverage restored after ending Oct 1, 2025 |
| North Dakota | Not covered | Weight-loss coverage is limited to phentermine, bupropion, naltrexone and topiramate; no GLP-1 is covered for weight loss. [82][83] | Covered with PA (ages 55 to 74, after Ozempic or Rybelsus) | Not confirmed | No 2025 or 2026 change found |
| Ohio | Not covered | Ohio Administrative Code rule 5160-9-03 excludes drugs for the treatment of obesity. [84][85] | Covered with PA (no diabetes) | Not confirmed | Jan 7, 2026: P&T committee recommended Wegovy as preferred with PA in a new non-obesity class |
| Oklahoma | Not covered | Wegovy is not approved without established heart disease and Zepbound is not approved without sleep apnea (PA criteria, Oct 1, 2026). [86] | Covered with PA (age 45+, BMI 27+) | Covered with PA (BMI 30+) | No 2025 or 2026 change found |
| Oregon | Not covered | Drugs prescribed only for weight management are not covered for adults; under 21, case-by-case review. [87] | Covered with PA | Covered with PA (BMI 30+) | Mar 1, 2026: weight management criteria updated |
| Pennsylvania | Ended in 2026 | Coverage for overweight and obesity ended Jan 1, 2026 for adults 21 and older, in fee-for-service and managed care. Under 21 is reviewed under EPSDT. Saxenda is not covered for any use. [88][89][90] | Covered with PA (BMI 27+) | Covered with PA (BMI 35+) | Jan 1, 2026: weight-loss coverage ended; earlier PAs expired Dec 31, 2025 |
| Rhode Island | Ended in 2026 | Foundayo, Saxenda, Wegovy and Zepbound are not covered when prescribed solely for weight loss from Oct 1, 2026, under the state fiscal 2027 budget. Under 21: EPSDT review. [91][2] | New PA required (criteria not published) | New PA required (criteria not published) | Oct 1, 2026: weight-loss coverage ended |
| South Carolina | Ended in 2026 | Coverage began Nov 1, 2024 and ended Jan 1, 2026; obesity GLP-1s were removed from the PDL Dec 31, 2025. Diabetes coverage continues. [92][93] | Covered with PA | Not confirmed | Jan 1, 2026: weight-loss coverage ended |
| South Dakota | Not covered | The pharmacy manual lists agents used for weight loss as non-covered. [94][95][96] | Covered with PA | Covered with PA | No 2025 or 2026 change found |
| Tennessee | Covered | Wegovy and Zepbound preferred, Saxenda non-preferred, with PA: BMI 30 or more, or 27 with a weight-related condition, plus nutrition and lifestyle changes. Renewal needs 5% loss. Coverage began Aug 1, 2025. [97][98][99] | Covered with PA (BMI over 27) | Covered with PA (after 3 months of CPAP or BiPAP) | Aug 1, 2025: weight-loss coverage added |
| Texas | Not covered | Weight management drugs outside specific exceptions are not covered for traditional Medicaid clients 21 and over. [100][101][102] | Covered with PA (age 45+) | Covered with PA (AHI 15+) | Sep 10, 2026: diabetes GLP-1 criteria revised |
| Utah | Ended in 2026 | A one-year fee-for-service weight-loss pilot that began July 1, 2025 ended June 30, 2026. The PA form said coverage may not continue past that date; we found no state notice of the end. [103][2][3] | Covered with PA (BMI 27+) | Covered with PA (BMI 30+, PAP use) | Jun 30, 2026: weight-loss pilot expired |
| Vermont | Not covered | The PDL (Oct 2, 2026) lists drugs used for weight loss as a policy exclusion. [104][105][106] | Covered with PA (BMI over 27) | Covered with PA (BMI over 30) | No 2025 or 2026 change found |
| Virginia | Covered with limits | BMI over 40, or over 37 with dyslipidemia, hypertension or type 2 diabetes, after trying a non-GLP-1 weight-loss drug and the preferred product. Wegovy, Zepbound, Saxenda and Foundayo; renewals stop below BMI 25. [107][108] | Not confirmed | Not confirmed | Jul 1, 2026: new form adds Foundayo and Wegovy tablets |
| Washington | Not covered | Apple Health policies say Wegovy and Zepbound are not covered for weight loss; the Wegovy policy cites WAC 182-530-2100 and SSA 1927(d)(2)(A). [109][110][111] | Covered with PA (no diabetes) | Covered with PA (no diabetes) | Mar 12, 2026: bill to require coverage (HB 1326) died |
| West Virginia | Not covered | Agents used for weight loss are a benefit exclusion. [112][113] | Covered with PA (BMI 27+) | Covered with PA (BMI 30+) | Jan 1, 2026: updated Wegovy criteria |
| Wisconsin | Covered with limits | New weight management class from July 1, 2026: Zepbound and Foundayo preferred, PA for every drug. BMI 30 or more, or 27 to under 30 with two or more risk factors. Saxenda and older drugs dropped. [114][115] | Covered with PA (BMI 27+) | Via weight-loss PA | Jul 1, 2026: new weight management drug class |
| Wyoming | Not covered | The 2024 provider manual (Revision 26) excludes “anorexiant products” for all Medicaid plans, and the June 2026 criteria require heart disease for Wegovy and sleep apnea for Zepbound. [116][117] | Covered with PA (BMI 27+) | Covered with PA (AHI over 15) | No 2025 or 2026 change found |
Why most states can say no
Federal Medicaid law requires states to cover most outpatient drugs, but it lists a few classes a state may leave out. The lead-in reads: “The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:” The first item on the list, section 1927(d)(2)(A) of the Social Security Act, is “Agents when used for anorexia, weight loss, or weight gain.” [1] KFF puts it plainly: Medicaid coverage of GLP-1s for obesity treatment is optional for states [3].
The words “when used for” are why the other uses are different. The exclusion is tied to the purpose, not the drug. When the same medicine is prescribed for another FDA-approved use, the weight-loss exclusion does not apply, and KFF says coverage for diabetes, cardiovascular disease and sleep apnea is required [3]. Stateline reported that every state Medicaid program covers GLP-1s for type 2 diabetes and heart conditions [118].
- Heart risk. FDA approved Wegovy on Mar 8, 2024 to lower the risk of heart attack, stroke and cardiovascular death in adults with heart disease and obesity or overweight [119]. Most states cover it with PA, usually asking for BMI 27 or more and a prior heart attack, stroke or symptomatic peripheral artery disease. Some go further: New York asks for BMI over 40 [78], and North Dakota limits it to ages 55 to 74, after a dose of Ozempic or Rybelsus is tolerated first [83].
- Sleep apnea. FDA approved Zepbound on Dec 20, 2024 for moderate to severe obstructive sleep apnea in adults with obesity [120]. State criteria usually ask for a sleep study with an apnea-hypopnea index of 15 or more and BMI 30 or more; Pennsylvania asks for BMI 35 or more [89], and Montana wants six months on a breathing machine first [67].
- MASH. Wegovy injection is approved for noncirrhotic MASH with moderate to advanced liver fibrosis in adults [121]. Several states list it next to heart risk, among them Alaska [8], Arkansas [11] and Illinois [35].
- Type 2 diabetes. Ozempic and Mounjaro are diabetes drugs, not weight-loss drugs [122][123]. States put them on their drug lists for diabetes, often with a required diagnosis code, as in Idaho [33] and Texas [124]. A diabetes approval does not open a weight-loss path.
Washington's Wegovy policy shows how this works on paper: it cites the state rule and the federal statute to exclude weight loss, then covers the same drug for heart risk and MASH [109]. In our table, 41 programs have a documented heart-risk pathway for Wegovy and 37 a documented sleep apnea pathway for Zepbound. The rest are not confirmed, which here means the criteria were not found or could not be read.
What changed in 2025 and 2026
Newest first. Dates are the dates the change took effect, unless marked as announced or scheduled.
- Jan 1, 2027 (scheduled): Louisiana's Act 898 requires Medicaid to cover FDA-approved weight-loss drugs, with criteria set by the Louisiana Department of Health, subject to legislative appropriation [45][126]. Whether money was appropriated is not confirmed.
- Nov 1, 2026 (scheduled): Michigan adds Foundayo as a non-preferred weight-loss drug and moves Mounjaro to preferred [58].
- Oct 1, 2026: Rhode Island stopped covering Foundayo, Saxenda, Wegovy and Zepbound when prescribed solely for weight loss, under its fiscal 2027 budget [91]. Rhode Island Current called it at least the seventh state in 2026 to end or not renew coverage [2].
- Aug 2026: Florida declined the federal BALANCE model, citing new, unbudgeted spending [27].
- Jul 30, 2026 (announced): Indiana's governor said Medicaid will cover select GLP-1s for obesity through BALANCE [37]. As of Aug 10, 2026 no start date had been announced [38].
- Jul 3, 2026: MassHealth ended coverage of Wegovy, Zepbound and other drugs used for weight loss, for members in every plan type [54]. News reports gave July 1 as the date; MassHealth's notice says July 3 [55][125]. Officials said at least 22,000 people were affected [55]. Details: MassHealth and GLP-1s.
- Jul 1, 2026: Wisconsin created a weight management drug class with Zepbound and Foundayo preferred and prior authorization for every drug [114].
- Jul 1, 2026: Mississippi's new criteria list Foundayo, and adult claims with an obesity diagnosis code can now be approved electronically for up to 12 months [62][63].
- Jul 1, 2026: Virginia's new weight-loss form added Foundayo and Wegovy tablets and kept its BMI 40 rule (BMI 37 with a risk factor) [107].
- Jun 30, 2026: Utah's one-year fee-for-service weight-loss pilot ended; its form said coverage may not continue past that date [103][2].
- Jun 9, 2026: Louisiana's SB 433 was signed and became Act 898 [126].
- Mar 25, 2026: A Minnesota bill to bar Medical Assistance coverage of drugs used solely for weight loss (HF4142) was laid over in committee [61].
- Feb 17, 2026: MassHealth added Wegovy as preferred alongside Zepbound and tightened adult criteria to BMI 35, or lower BMI with listed conditions, months before ending coverage [127].
- Jan 1, 2026: California [13], New Hampshire [73], Pennsylvania [88] and South Carolina [92] ended weight-loss coverage; KFF lists the four together [3]. Pennsylvania's cut applies to adults 21 and older, and California's to adults. See Medi-Cal and GLP-1s.
- Jan 1, 2026: Michigan limited weight-loss coverage to BMI 40 or more, after trials of older drugs, and only to avoid bariatric surgery [56].
- Dec 12, 2025: North Carolina restored coverage, returning to the rules in place on Sep 30, 2025 [79].
- Oct 1, 2025: North Carolina ended coverage and removed Wegovy, Zepbound and Saxenda from its drug list [80].
- Aug 1, 2025: Tennessee began covering Wegovy and Zepbound for weight loss with prior authorization [97].
- Jul 1, 2025: Utah's pilot began, per Milliman [128], and Connecticut began covering Zepbound for sleep apnea [19].
- Jun 1, 2025: Connecticut's state plan limited weight-loss drugs to orlistat and phentermine [17].
- Jan 9, 2025: Missouri's criteria covering Zepbound for obesity were first implemented [64].
The CMS BALANCE model
BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) is a CMS Innovation Center model meant to lower what Medicaid and Medicare pay for GLP-1s [129]. State Medicaid agencies can join from May 2026 through Jan 1, 2027 [130]. KFF reported that state applications were due July 31, 2026, with rolling starts [131]. The drugs listed are all forms of Mounjaro, Ozempic, Rybelsus and Wegovy, plus Zepbound KwikPen and Foundayo, and states in the Medicaid Drug Rebate Program are eligible [130].
- Who has joined: Indiana is the only state that has said so publicly. In late August, Health Policy Ohio, summarizing POLITICO's survey, reported that 29 programs said they would not take part and that Ohio, Arizona, Georgia, Michigan, Montana, Tennessee and Virginia had not decided [132]. Florida said no [27].
- What Indiana said it pays: $245 per member per month to manufacturers, or $85.16 per month in state money after the federal share, with a lifestyle program from the manufacturers at no added cost [37].
- Medicare: the CMS page now refers only to a “potential implementation of BALANCE in Part D” and runs the Medicare GLP-1 Bridge through Dec 31, 2027 [130].
- What is not known: CMS lists no participating states (its page shows the number of participants as N/A) [130], and no state prices; it says Medicaid coverage will depend on participation by manufacturers and states. Which states applied by July 31 is not public, and Indiana had not set a start date as of Aug 10, 2026 [38].
If your state does not cover it
Start with your own plan, because coverage can differ between fee-for-service and managed care plans in the same state. Call the member services number on your card and ask three things: whether the drug is on the plan's drug list for your use, what the prior authorization criteria are, and how to appeal a denial. Your prescriber submits the prior authorization request; if it is denied, ask the plan how to appeal. Members under 21 can ask for a medical-necessity review under EPSDT, which California, Pennsylvania, Massachusetts and Rhode Island name in their notices [13][88][54][91].
- Heart disease and overweight or obesity: ask about Wegovy's heart-risk use. It is covered with PA in most states in the table, including states that exclude weight loss.
- Moderate to severe sleep apnea: ask about Zepbound's sleep apnea use, which usually needs a recent sleep study. In Massachusetts, Wegovy must be tried first [54].
- Type 2 diabetes: Ozempic and Mounjaro are covered for diabetes in Medicaid, and KFF says that coverage is required [3].
If none of those apply, the fallback is paying cash. Manufacturer savings cards do not work for Medicaid, because they exclude government beneficiaries [133][134], but NovoCare says people in government programs may pay its self-pay price [134]. Prices checked Oct 17, 2026:
| Drug | Where | Monthly price | Conditions | Source |
|---|---|---|---|---|
| Zepbound (vial or KwikPen) | LillyDirect | $299 to $449 | $299 for 2.5 mg, $399 for 5 mg, $449 for 7.5 to 15 mg if refilled within 45 days; otherwise $499 to $699 | [135] |
| Wegovy pen | NovoCare Pharmacy | $199 to $399 | $349 for standard doses; $199 for the first two fills of 0.25 mg and 0.5 mg, through Dec 31, 2026; Wegovy HD 7.2 mg is $399 | [134] |
| Wegovy pill | NovoCare and retail pharmacies | $149 to $299 | $149 for 1.5 mg, $199 for 4 mg, $299 for 9 mg and 25 mg | [134] |
| Foundayo pill | LillyDirect | $149 to $299 | $149 for 0.8 mg and 2.5 mg, $199 for 5.5 mg, $299 for 9 to 17.2 mg; 2.5 mg and 5.5 mg prices are temporarily reduced through Dec 31, 2026, and 14.5 mg and 17.2 mg need a refill within 45 days | [136] |
Full price breakdowns, with what each price includes, are on Zepbound cost, Wegovy cost and GLP-1 cost. For employer and marketplace plans, see GLP-1 insurance coverage.
If you also have Medicare Part D, the Medicare GLP-1 Bridge covers Wegovy, Foundayo and Zepbound KwikPen for weight management from Jul 1, 2026 to Dec 31, 2027 for people who meet its BMI rules, at a $50 monthly copay that Extra Help does not reduce [138]. People with type 2 diabetes, moderate to severe sleep apnea or fatty liver disease are left out of the Bridge, since their regular Part D plan may cover the drug [138]. See Medicare and GLP-1s.
Safety on any GLP-1
Get medical help right away for severe stomach pain that will not go away, which can be a sign of pancreatitis, or for signs of an allergic reaction such as swelling of the face or trouble breathing. Wegovy and Zepbound carry a boxed warning about thyroid C-cell tumors, and their labels list acute pancreatitis among the warnings [121][139]. For an emergency, call 911.
How we check
We read each program's own documents: its preferred drug list, prior authorization criteria and forms, provider bulletins, state rules and, where they exist, laws and budget notices. When a state's document could not be opened, we used a secondary source that quotes it and say so in the row (Alabama and Nevada). When only a managed care plan's policy confirms a cell, the row says so (Florida and Nebraska). Hawaii's coverage is set in each managed care plan's formulary, so its row is plan by plan. We checked every row ourselves on Oct 18, 2026, against the sources cited in it.
- Covered: the program covers at least one GLP-1 for weight loss with PA under rules close to the FDA label, BMI 30 or more, or 27 or more with a weight-related condition [121] [139].
- Covered with limits: coverage exists, but the rules are stricter than the label, such as a BMI 40 floor (Michigan) [57], BMI 40 or 37 with a risk factor (Virginia) [107] or two risk factors instead of one (Wisconsin) [114].
- Ended in 2026: the program covered weight loss and stopped during 2026. North Carolina ended coverage in October 2025 but restored it in December 2025, so it is listed as Covered [79] [80].
- Not covered: a state document, or a secondary source quoting one, says GLP-1s are not covered for weight loss.
- Not confirmed: documents conflict or none states the rule (DC and Idaho).
Our count is not the same measure as KFF's. KFF counted 13 programs covering GLP-1s for obesity under fee-for-service as of January 2026 and did not name all 13 in its text [3]. Stateline, citing KFF, named ten of them in April: Delaware, Kansas, Michigan, Minnesota, Mississippi, Missouri, Tennessee, Utah, Virginia and Wisconsin [41]. Since January, Utah, Massachusetts and Rhode Island have ended coverage, and our table counts North Carolina, which restored coverage in December 2025.
Rules change often, and a drug list can lag a bulletin by weeks. If you see a change, or a document we missed, email [email protected] with the link and we will update the row and its date. Our editorial standards explain how we source and correct pages.
Questions people ask
Does Medicaid cover Wegovy for weight loss?
In most states, no. As of Oct 18, 2026, 10 of 51 Medicaid programs covered a GLP-1 for weight loss, and in Missouri that coverage is Zepbound, not Wegovy [64]. Federal law lets states exclude drugs used for weight loss [1]. Wegovy for heart risk is a separate use, and KFF says Medicaid coverage for cardiovascular disease is required [3].
Does Medicaid cover Zepbound?
For weight loss, only in the programs that cover obesity drugs, such as Mississippi, Missouri, Tennessee and Wisconsin [63][64][97][114]. For moderate to severe obstructive sleep apnea, which FDA approved in December 2024 [120], most programs cover Zepbound with prior authorization, and KFF says coverage for sleep apnea is required [3].
Does Medicaid cover Ozempic for weight loss?
Ozempic is approved for type 2 diabetes, not weight loss [122], and none of the 10 programs that covered weight loss on Oct 18, 2026 listed Ozempic for it in the documents we read. Medicaid covers Ozempic for type 2 diabetes, often with a required diabetes diagnosis, and KFF says diabetes coverage is required [3].
Does Medicaid cover Mounjaro?
Does Medicaid cover tirzepatide?
Tirzepatide is sold as Mounjaro for type 2 diabetes and as Zepbound for weight loss and sleep apnea [141]. Medicaid covers it for diabetes, and most programs cover Zepbound for sleep apnea with prior authorization. For weight loss alone, 10 of 51 programs covered a GLP-1 as of Oct 18, 2026. Compounded tirzepatide is not FDA-approved.
Does Medicaid cover GLP-1s or weight loss medication?
It depends on the state. As of Oct 18, 2026, Delaware, Kansas, Minnesota, Mississippi, Missouri, North Carolina and Tennessee covered GLP-1s for weight loss under rules close to the FDA label, and Michigan, Virginia and Wisconsin covered them with tighter limits. Seven programs ended coverage in 2026, including Rhode Island on Oct 1 [91]. Some states that exclude GLP-1s still cover older drugs: Connecticut covers orlistat and phentermine [17].
Did Medicaid stop covering Wegovy?
Seven programs stopped covering GLP-1s for weight loss in 2026: California, New Hampshire, Pennsylvania and South Carolina on Jan 1, Utah on Jun 30, Massachusetts on Jul 3 (news reports said July 1), and Rhode Island on Oct 1 [3][103][54][91]. In each, Wegovy for other approved uses, such as heart risk, stayed available, usually with prior authorization.
How do I get Wegovy covered by Medicaid?
Ask your plan for its Wegovy prior authorization criteria and which uses it covers. If you have heart disease with overweight or obesity, most states cover Wegovy for heart risk, usually with BMI 27 or more and a prior heart attack, stroke or peripheral artery disease. If your state excludes weight loss and no other use fits, NovoCare sells Wegovy pens for $349 a month at standard doses, checked Oct 17, 2026 [134].
Sources
147 cited
- Social Security Act section 1927: payment for covered outpatient drugs. Social Security Administration, Oct 18, 2026.
- 5 changes for Rhode Island Medicaid coming Oct. 1. Rhode Island Current, Oct 1, 2026.
- Medicaid coverage of and spending on GLP-1s. KFF, Jan 16, 2026.
- Medicaid and CHIP monthly enrollment, June 2026. KFF State Health Facts, Oct 18, 2026.
- Medicaid GLP-1 coverage by state. The Rx Index, Sep 28, 2026.
- HJR162: encouraging the Alabama Medicaid Agency to evaluate the costs of GLP-1 medications. Alabama Legislature, Mar 5, 2026.
- Does Medicaid cover Zepbound?. SingleCare, Jan 2, 2026.
- Semaglutide criteria, Version 2. Alaska Department of Health, Sep 18, 2026.
- Tirzepatide criteria, Version 2. Alaska Department of Health, Sep 18, 2026.
- AMPM 310-V: prescription medications and pharmacy services. AHCCCS, Oct 9, 2026.
- Arkansas Medicaid April 2026 DUR provider memo. Arkansas Medicaid (Prime Therapeutics), May 13, 2026.
- Arkansas Medicaid prior authorization criteria. Arkansas Medicaid (Prime Therapeutics), Oct 1, 2026.
- GLP-1 coverage considerations. Medi-Cal Rx (DHCS), Apr 6, 2026.
- DHCS 2025-26 Budget Act highlights. California DHCS, Jul 1, 2025.
- Changes to GLP-1 drug coverage: Wegovy. Medi-Cal Rx (DHCS), Apr 6, 2026.
- Appendix P, effective Oct 1, 2026. Colorado HCPF, Oct 1, 2026.
- Connecticut state plan amendment 25-0014. CMS (Medicaid.gov), Jun 3, 2025.
- Provider bulletin 2025-54: Wegovy coverage. Connecticut DSS, Oct 2025.
- Provider bulletin 2025-32: Zepbound for obstructive sleep apnea. Connecticut DSS, Jun 2025.
- GLP-1 agonist for weight management, MASH or prevention of MACE: PA form. Delaware DHSS, Apr 20, 2026.
- DE.PMN.50 anti-obesity medications. Delaware First Health, Apr 2026.
- District FFS pharmacy provider manual. DHCF (Prime Therapeutics), Aug 28, 2023.
- MedStar Family Choice DC formulary, Jan 1, 2026. MedStar Family Choice DC, Jan 1, 2026.
- Transmittal 26-19: managed care plan transition. DC DHCF, Jul 2, 2026.
- Final order 24-FH0081 quoting the Florida Medicaid Prescribed Drugs Coverage Policy. Florida Health Justice Project library, Apr 17, 2024.
- Wegovy (CV, MASH) and Zepbound (OSA) Medicaid policy. Aetna Better Health, Sep 1, 2026.
- States reject discounted Medicaid GLP-1 deal. Becker's Payer Issues, Aug 25, 2026.
- Georgia Medicaid PDL by drug class, Oct 1, 2026. Georgia DCH, Oct 1, 2026.
- DCH decision document, November 2025. Georgia DCH, Jan 1, 2026.
- SB 3195 (2026). Hawaii State Legislature, 2026.
- AlohaCare QUEST formulary. AlohaCare, Oct 9, 2026.
- UnitedHealthcare Community Plan Hawaii QUEST preferred drug list. UnitedHealthcare Community Plan, Oct 1, 2026.
- Idaho Medicaid preferred drug list. Idaho DHW, Jul 1, 2026.
- IDAPA 16.03.09.662. Legal Information Institute, Mar 17, 2022.
- Illinois Medicaid preferred drug list, Oct 1, 2026. Illinois HFS, Oct 1, 2026.
- GLP-1 RA and GIP combination PA criteria. Indiana Medicaid (OptumRx), Dec 1, 2025.
- Governor Braun announces state Medicaid program will cover GLP-1 treatments for eligible beneficiaries. State of Indiana, Jul 30, 2026.
- Indiana Medicaid weight-loss drug coverage. Mirror Indy, Aug 10, 2026.
- Incretin mimetics for non-diabetes indications: PA form 470-0058. Iowa Medicaid, Jan 2026.
- Anti-obesity medications PA criteria. Kansas KDHE, Aug 19, 2026.
- More states consider dropping GLP-1 weight-loss drugs from Medicaid. Stateline, Apr 30, 2026.
- 907 KAR 23:010. Kentucky Legislature, Jul 22, 2024.
- Wegovy PA criteria. Kentucky Medicaid (MedImpact), Jan 3, 2026.
- Zepbound PA criteria. Kentucky Medicaid (MedImpact), 2025.
- SB 433 (2026 Regular Session), reengrossed. Louisiana State Legislature, 2026.
- Wegovy PA criteria. Louisiana Department of Health, Nov 2025.
- Zepbound PA criteria. Louisiana Department of Health, Jun 2025.
- Semaglutide for MACE reduction: PA form. MaineCare, Mar 2026.
- MaineCare DUR Board minutes, March 2025. MaineCare, Mar 11, 2025.
- Maine LD 480 (2025). LegiScan, Mar 20, 2025.
- COMAR 10.09.03.05. Maryland Division of State Documents, Oct 18, 2026.
- Wegovy or Zepbound PA form. Maryland Department of Health, Dec 2025.
- Draft recommendations on CMMI models. Maryland Prescription Drug Affordability Board, May 11, 2026.
- MassHealth Pharmacy Facts 276. MassHealth, May 13, 2026.
- Mass. cutting GLP-1 coverage in Medicaid. WBUR, Jun 23, 2026.
- Numbered Letter L 25-73: pharmacy. Michigan MDHHS, Dec 8, 2025.
- Anti-obesity agents and non-preferred GLP-1s: criteria. Michigan Medicaid (Prime Therapeutics), Jan 1, 2026.
- Michigan Single PDL changes. Michigan Medicaid (Prime Therapeutics), Oct 18, 2026.
- Minnesota preferred drug list, Jan 1, 2026. Minnesota DHS, Jan 1, 2026.
- Anti-obesity medications PA criteria. Minnesota DHS, Aug 4, 2026.
- Bill would bar Medical Assistance coverage of weight-loss drugs. Minnesota House Session Daily, Mar 25, 2026.
- Anti-obesity select agents PA criteria, V11. Mississippi Division of Medicaid, Jul 1, 2026.
- Provider education on prescribing select anti-obesity agents. Mississippi Division of Medicaid, Jul 1, 2026.
- GLP-1s for obesity: criteria proposal. Missouri DSS (MO HealthNet), Oct 14, 2025.
- GLP-1 receptor agonists PA form 2575-053. Missouri DSS (MO HealthNet), Jan 27, 2026.
- Montana Medicaid pharmacy program. Montana DPHHS, Oct 18, 2026.
- Montana DUR newsletter, Spring 2026. Mountain-Pacific Quality Health, Mar 2026.
- Medicaid services. Nebraska DHHS, Oct 18, 2026.
- Wegovy PA fax form. Nebraska Medicaid, Jan 2026.
- NE.PMN.298 tirzepatide (Zepbound). Nebraska Total Care, Jun 4, 2026.
- Web Announcement 3337: Wegovy coverage. Nevada Medicaid, Apr 22, 2024.
- Web Announcement 3808: DUR Board changes. Nevada Medicaid, Jan 5, 2026.
- Notification: GLP-1 coverage change. New Hampshire Medicaid (Prime Therapeutics), Oct 9, 2025.
- N.J.A.C. 10:51 pharmaceutical services manual. New Jersey Department of Human Services, Jun 16, 2025.
- GLP-1 coverage cost memo. New Jersey DMAHS, Aug 2025.
- Weight reduction medications. New Mexico Health Care Authority, Mar 4, 2025.
- NYRx pharmacy policy guidelines, version 2026-3. New York State Department of Health (eMedNY), Sep 2026.
- NYRx Wegovy coverage overview. NYRx, Jul 23, 2026.
- NC Medicaid to reinstitute coverage of GLP-1s for weight management. NC Medicaid (NCDHHS), Dec 19, 2025.
- NC Medicaid change in coverage of GLP-1 weight management medications. NC Medicaid (NCDHHS), Sep 5, 2025.
- PDL changes effective Oct 1, 2026. Carolina Complete Health, Oct 1, 2026.
- Pharmacy provider manual: exclusions. North Dakota HHS, Jun 1, 2026.
- North Dakota Medicaid PDL, version 2026.6. North Dakota Medicaid (Acentra), Jul 31, 2026.
- OAC 5160-9-03. Ohio Laws and Administrative Rules, Feb 16, 2024.
- P&T committee meeting minutes, Jan 7, 2026. Ohio Department of Medicaid, Jan 7, 2026.
- Metabolic disorders PA criteria. Oklahoma Health Care Authority, Oct 1, 2026.
- Weight management drugs PA criteria. Oregon Health Plan (orpdl.org), Mar 1, 2026.
- Medical Assistance Bulletin: GLP-1 coverage changes. Pennsylvania DHS, Nov 24, 2025.
- GLP-1 receptor agonists standard request form. Pennsylvania DHS, Mar 2, 2026.
- PA Medicaid ends adult coverage of GLP-1s for weight loss. Pennsylvania Health Law Project, Dec 22, 2025.
- GLP-1 coverage change effective Oct 1, 2026. Rhode Island EOHHS, Aug 5, 2026.
- P&T committee minutes, Nov 5, 2025. South Carolina DHHS, Nov 5, 2025.
- SC Medicaid program to stop covering expensive weight-loss drugs for obesity. SC Daily Gazette, Nov 17, 2025.
- Pharmacy services billing manual. South Dakota DSS, May 26, 2026.
- Wegovy PA request form. South Dakota Medicaid (OptumRx), Apr 2026.
- Zepbound for OSA PA request form. South Dakota Medicaid (OptumRx), May 2026.
- Provider notice: obesity management agents. TennCare (OptumRx), Aug 1, 2025.
- Obesity management agents PA form. TennCare (OptumRx), Aug 2026.
- GLP-1 agonists PA form. TennCare (OptumRx), Oct 2026.
- Weight management drugs. Texas HHSC Vendor Drug Program, Oct 18, 2026.
- Wegovy clinical criteria. Texas Medicaid (Acentra), May 8, 2026.
- Zepbound clinical criteria. Texas Medicaid (Acentra), Oct 24, 2025.
- GLP-1 medications for weight-related comorbidities: PA form. Utah DHHS, Jun 1, 2026.
- Vermont Medicaid PDL, Oct 2, 2026. Vermont DVHA, Oct 2, 2026.
- Semaglutide MACE and MASH PA form. Vermont DVHA, Apr 2026.
- Zepbound OSA PA form. Vermont DVHA, Oct 18, 2026.
- Weight loss management service authorization form. Virginia DMAS, Jul 1, 2026.
- Upcoming changes to service authorization criteria for weight loss drugs. Virginia DMAS, Jun 23, 2023.
- Semaglutide (Wegovy) policy. Washington HCA, Feb 1, 2026.
- Tirzepatide (Zepbound) policy. Washington HCA, May 1, 2025.
- Washington HB 1326. BillTrack50, Oct 18, 2026.
- Zepbound PA criteria. West Virginia BMS, Jul 1, 2025.
- Wegovy PA criteria. West Virginia BMS, Jan 1, 2026.
- ForwardHealth Update 2026-15. Wisconsin DHS (ForwardHealth), Jun 2026.
- PDL quick reference, Sep 1, 2026. Wisconsin DHS (ForwardHealth), Sep 1, 2026.
- Wyoming Medicaid provider manual, revision 26. Wyoming Department of Health, Oct 10, 2024.
- Wyoming Medicaid clinical criteria, Jun 8, 2026. Wyoming Department of Health, Jun 8, 2026.
- States retreat from covering drugs for weight loss. Stateline, Nov 28, 2025.
- FDA approves first treatment to reduce risk of serious heart problems specifically in adults with obesity or overweight. US Food and Drug Administration, Mar 8, 2024.
- FDA approves first medication for obstructive sleep apnea. US Food and Drug Administration, Dec 20, 2024.
- Wegovy (semaglutide) label. DailyMed (National Library of Medicine), Jun 2026.
- Ozempic self-pay and savings. Novo Nordisk (NovoCare), Oct 17, 2026.
- Mounjaro FAQ. Eli Lilly and Company, Oct 17, 2026.
- GLP-1 receptor agonists clinical criteria. Texas Medicaid (Acentra), Sep 10, 2026.
- MassHealth will stop covering weight-loss drugs next week. Boston.com, Jun 27, 2026.
- Louisiana SB 433 (2026): bill status. FastDemocracy, Oct 18, 2026.
- MassHealth Pharmacy Facts 269. MassHealth, Jan 14, 2026.
- The evolving landscape of obesity coverage in Medicaid. Milliman, Mar 19, 2026.
- Innovation insight: affordability of GLP-1s takes next step with BALANCE model RFAs. CMS, Mar 9, 2026.
- BALANCE Model. CMS Innovation Center, Sep 29, 2026.
- What to know about the BALANCE model for GLP-1s in Medicare and Medicaid. KFF, May 11, 2026.
- Indiana only state to join federal program to offer GLP-1 drugs through Medicaid. Health Policy Ohio, Aug 28, 2026.
- Zepbound coverage and savings. Eli Lilly and Company, Oct 17, 2026.
- Wegovy self-pay offer. Novo Nordisk (NovoCare), Oct 17, 2026.
- Zepbound self-pay pricing. Eli Lilly and Company (LillyDirect), Oct 17, 2026.
- Foundayo self-pay pricing. Eli Lilly and Company (LillyDirect), Oct 17, 2026.
- TrumpRx.gov. TrumpRx.gov (US government), Oct 17, 2026.
- Weight loss drugs coverage. Medicare.gov (CMS), Oct 17, 2026.
- Zepbound (tirzepatide) prescribing information. US Food and Drug Administration, Apr 2026.
- Provider alert: PDL changes effective Jan 1, 2026. Alabama Medicaid Agency, Dec 8, 2025.
- Zepbound FAQ. Eli Lilly and Company, Oct 17, 2026.
- NC Medicaid preferred drug list, effective October 2026. NC Medicaid (NCDHHS), Sep 14, 2026.
- GLP-1s for weight management: prior approval criteria (effective Aug 1, 2024). NC Medicaid (NCTracks), Aug 1, 2024.
- GLP-1 medications for weight loss will no longer be covered by Medi-Cal. California Medical Association, Dec 2, 2025.
- AR Medicaid PA edits and PDL updates approved at the Oct 15, 2025 DUR Board meeting. Arkansas Medicaid (Prime Therapeutics), Nov 12, 2025.
- HB 2456 (2026): DHS; weight loss; obesity; Medicaid; GLP-1. CalMatters Digital Democracy (Civil Beat), Feb 18, 2026.
- SB 3195 (2026): DHS; weight loss; obesity; Medicare; Medicaid; GLP-1. CalMatters Digital Democracy (Civil Beat), Feb 2, 2026.
This page is general information, not medical advice. Talk with a licensed clinician about your own care.