Medicaid GLP-1 Coverage for Weight Loss by State: October 2026
Fewer state Medicaid programs cover GLP-1s for weight loss than a year ago. KFF counted 13 states covering them in January 2026, down from 16 in October 2025, and since then Utah's fee-for-service program, Massachusetts and Rhode Island have ended weight-loss-only coverage while Indiana announced it will add coverage through the federal BALANCE model. Coverage for type 2 diabetes, heart risk reduction and sleep apnea is a separate, required benefit that continues in every state.
Key takeaways
- Weight-loss coverage is optional for state Medicaid programs. Seven states ended weight-loss-only coverage between January 1 and October 1, 2026, and Michigan sharply restricted it.
- States that still cover it all use prior authorization, usually tied to BMI and a lifestyle program, and some (Virginia, Michigan) set the bar much higher.
- Diabetes, cardiovascular and sleep apnea uses must still be covered, so a coverage cut does not end every GLP-1 prescription.
- States can join the BALANCE model through January 1, 2027. CMS's model page lists no participating states yet; Indiana has announced it will join.
- Your managed care plan may apply its own criteria, so ask the plan, not just the state.
Each table row below comes from the state's own Medicaid notice, PDL bulletin or PA criteria, or from KFF and Milliman where noted, with the document date shown. Pages were reviewed as of October 19, 2026. States not listed were not verified here.
Why coverage is shrinking
Federal law lets states choose whether Medicaid covers drugs for weight loss. As of January 2026, KFF counted 13 state programs covering GLP-1s for obesity under fee-for-service, down from 16 in its October 2025 survey. California, New Hampshire, Pennsylvania and South Carolina dropped coverage, and North Carolina dropped it and then reinstated it.
Cost drove most of the cuts. A March 2026 Milliman analysis found that California, Pennsylvania, New Hampshire and South Carolina together spent about $2.5 billion (gross, for all approved uses) on Wegovy, Zepbound and Saxenda over a 30-month span from 2023 through mid-2025, before ending weight-loss coverage. Massachusetts officials said the July 2026 cut would save about $15 million a year and affect at least 22,000 members, WBUR reported.
State-by-state status, October 2026
States with verified weight-loss coverage (prior authorization required)
| State | Status and key criteria | Source and date |
|---|---|---|
| Delaware | Fee-for-service PA form includes a weight-management pathway: BMI 30+, or 27 to 30 with a condition such as hypertension or sleep apnea. Managed care plans use their own criteria. | DMAP PA form, rev. April 2026 |
| Kansas | Wegovy, Zepbound, Saxenda and Foundayo with PA; BMI 30+, or 27+ with a weight-related condition, plus a lifestyle plan. | KDHE criteria, reviewed Aug. 19, 2026 |
| Michigan | Restricted since Jan. 1, 2026: weight-only requests limited to morbid obesity after other interventions fail, to avoid bariatric surgery. | MDHHS L-25-73, Dec. 8, 2025 |
| Mississippi | Foundayo, Saxenda, Wegovy and Zepbound preferred with PA; BMI 30+, or 27 to 29 with a comorbidity; treatment plan required. | MS Medicaid criteria, July 1, 2026 |
| North Carolina | Reinstated Dec. 12, 2025. Wegovy preferred; Zepbound and Saxenda require trying Wegovy first. | NC Medicaid, Dec. 19, 2025 |
| Tennessee | Coverage began Aug. 1, 2025, under interim PA criteria. Wegovy and Zepbound preferred with PA; adults need BMI 30+, or 27+ with a weight-related condition. | TennCare notice, Aug. 1, 2025 |
| Virginia | Highly restricted: GLP-1s require BMI over 40, or over 37 with dyslipidemia, hypertension or type 2 diabetes, plus a failed trial of a non-GLP-1 drug. | DMAS form, eff. July 1, 2026 |
| Wisconsin | New weight-management class July 1, 2026. Foundayo and Zepbound preferred with PA; BMI 30+, or 27 to 30 with two risk factors. Saxenda no longer covered. | ForwardHealth Update 2026-15, June 2026 |
Sources as linked in each row. Criteria are summarized; read the full document before applying.
States that ended weight-loss-only coverage
| State | Effective date | What still counts | Source |
|---|---|---|---|
| California (Medi-Cal) | Jan. 1, 2026 | Wegovy for MASH, without PA when the claim carries the MASH diagnosis code; "not covered for weight loss" | Medi-Cal Rx; Milliman |
| New Hampshire | Jan. 1, 2026 | Type 2 diabetes, cardiovascular events, severe sleep apnea, MASH | NH notice, Oct. 9, 2025 |
| Pennsylvania | Jan. 1, 2026 | Sleep apnea, MASH, cardiovascular risk reduction, with PA; Saxenda dropped for all uses | PA bulletin, Nov. 24, 2025 |
| South Carolina | Jan. 1, 2026 | Not detailed in source | Milliman, March 2026 |
| Utah (fee-for-service) | June 30, 2026 | Cardiovascular events, MASH, severe sleep apnea | Utah MIB 26-45, May 2026 |
| Massachusetts (MassHealth) | July 3, 2026 | BMI over 27 with heart disease, BMI over 30 with sleep apnea, MASH, under-21 EPSDT | Pharmacy Facts 276, May 13, 2026 |
| Rhode Island | Oct. 1, 2026 | Other medically necessary indications, with a new PA | RI EOHHS memo, Aug. 5, 2026 |
Sources as linked. Utah's bulletin addresses fee-for-service only; managed care members should ask their plan.
Every other state and DC: not verified for this page. KFF lists Connecticut, Louisiana, New Mexico, North Dakota and Texas among states that cover other weight-loss drugs but no GLP-1s as of January 2026. For any state, check the current preferred drug list and PA criteria on the state Medicaid pharmacy site.
Lost Medicaid coverage for weight loss?
If you choose to pay out of pocket, compare current self-pay prices before choosing a program.
Paid links. We may earn a commission; it never changes what we write. See all options. Compounded medications are not FDA-approved.
Diabetes and other medical uses are separate
A weight-loss cut does not touch GLP-1s prescribed for other approved uses. KFF explains that Medicaid must cover GLP-1 drugs approved for diabetes, Wegovy for cardiovascular risk reduction and Zepbound for moderate-to-severe sleep apnea in adults with obesity, plus coverage for children under EPSDT when medically necessary. States can still require prior authorization for those uses.
Expect paperwork when rules change. MassHealth ended all pre-February 17, 2026 approvals on July 2 and required resubmission, and made Wegovy the sole preferred drug for the remaining uses. Pennsylvania ended all existing GLP-1 approvals after December 31, 2025, regardless of condition. Rhode Island requires a new PA with clinical documentation for any non-weight use.
What the BALANCE model means for your state
BALANCE is a voluntary CMS Innovation Center model in which CMS negotiates GLP-1 prices and coverage terms with manufacturers for state Medicaid programs. Per the CMS model page (updated September 29, 2026), states can join from May 2026 through January 1, 2027, and included drugs are all forms of Mounjaro, Ozempic, Rybelsus and Wegovy, the Zepbound KwikPen and Foundayo, for current indications and weight management. Members also get a manufacturer-run lifestyle program at no cost.
According to KFF, the state application deadline was July 31, 2026, the Medicaid net price is confidential, and the model does not change members' out-of-pocket costs, which federal law already keeps nominal. CMS's page lists no participating states. Indiana's governor announced on July 30, 2026 that the state will join, with manufacturers supplying drugs at $245 per member per month and Indiana paying $85.16 after the federal share. Its start date and eligibility rules were still to be announced.
How to ask your plan
If you're in a Medicaid managed care plan, its rules and timing can differ from state fee-for-service rules. North Carolina told providers its health plans would update systems on their own timelines, and Delaware's PA form says its managed care plans apply their own criteria.
- Find your plan's member services number on your Medicaid card.
- Ask whether the specific drug is on the plan's formulary for weight management, and get the PA criteria.
- If weight-loss coverage ended, ask whether you qualify under another indication (diabetes, heart disease, sleep apnea, MASH).
- Ask your prescriber to submit any new PA before your current approval ends.
- Request any denial in writing, with the reason and how to appeal.
Questions to ask
- Does my plan follow the state's PDL for GLP-1s, or its own?
- Is my current approval still valid, and when does it end?
- Has the state joined BALANCE, and when would that coverage start?
- If I'm also on Medicare, which program pays first?
One caution if coverage ends: manufacturer copay cards exclude Medicaid enrollees. Novo Nordisk, for example, says Medicaid enrollees can't use its $25 offer but may buy through its self-pay options, which sit outside insurance.
Coverage denied or ended?
Compare care options and current self-pay prices before choosing a program.
Paid links. We may earn a commission; it never changes what we write. See all options. Compounded medications are not FDA-approved.
Frequently asked questions
Which states' Medicaid programs ended GLP-1 coverage for weight loss in 2026?
California, New Hampshire, Pennsylvania and South Carolina on January 1, 2026; Utah's fee-for-service program on June 30; Massachusetts on July 3; and Rhode Island on October 1, 2026, according to state notices and Milliman.
Does Medicaid still cover Ozempic or Mounjaro for diabetes?
Yes. KFF notes Medicaid must cover GLP-1s approved for diabetes, along with Wegovy for cardiovascular risk reduction and Zepbound for sleep apnea in adults with obesity. States can still require prior authorization.
What is the BALANCE model?
A voluntary CMS model that negotiates GLP-1 prices and coverage terms for state Medicaid programs, which can join from May 2026 through January 1, 2027. CMS's page lists no participating states yet; Indiana announced on July 30, 2026 that it will join.
Can I use a manufacturer savings card if Medicaid stops covering my GLP-1?
No. Manufacturer copay cards exclude Medicaid enrollees. Novo Nordisk says Medicaid enrollees may use its self-pay options, which are outside insurance.
Does my Medicaid managed care plan follow the state's rules?
Not always on the same timeline, and some states let plans set their own criteria. Ask your plan for its formulary status and prior authorization criteria for the specific drug.
Sources
- KFF: Medicaid coverage of and spending on GLP-1s (Jan. 16, 2026)
- Milliman: The evolving landscape of obesity coverage in Medicaid (March 19, 2026)
- WBUR: With Mass. cutting weight-loss drug coverage, patients scramble (June 23, 2026)
- Delaware Medicaid: GLP-1 agonist PA form (rev. April 2026)
- Kansas KDHE: Anti-obesity medications PA criteria (reviewed Aug. 19, 2026)
- Michigan MDHHS Numbered Letter L-25-73 (Dec. 8, 2025)
- Mississippi Medicaid: Anti-obesity select agents PA criteria (July 1, 2026)
- NC Medicaid: Reinstating coverage of GLP-1s for weight management (Dec. 19, 2025)
- TennCare: Obesity management agents provider notice (Aug. 1, 2025)
- Virginia DMAS: Weight-loss management service authorization form (eff. July 1, 2026)
- Wisconsin ForwardHealth Update 2026-15 (June 2026)
- Medi-Cal Rx: Changes to GLP-1 drug coverage, Wegovy (April 2026)
- New Hampshire Medicaid: GLP-1 coverage change notice (Oct. 9, 2025)
- Pennsylvania DHS Medical Assistance Bulletin (Nov. 24, 2025)
- Utah Medicaid Information Bulletin, May 2026 (item 26-45)
- MassHealth Pharmacy Facts 276 (May 13, 2026, corrected)
- Rhode Island EOHHS: GLP-1 change effective Oct. 1, 2026 (Aug. 5, 2026)
- CMS Innovation Center: BALANCE Model
- KFF: What to know about the BALANCE model (May 11, 2026)
- State of Indiana: Governor Braun announces Medicaid GLP-1 coverage (July 30, 2026)
- CMS: Medicare GLP-1 Bridge
- Ozempic.com: Save on Ozempic (eligibility terms)
Medical disclaimer: This article is general information, not medical advice, and does not replace a licensed clinician who knows your history. Approvals, labels, coverage and prices change; check the linked sources and talk with your prescriber or pharmacist before making decisions about any medication.