Does Medicaid Cover GLP-1s? Weight Loss Depends on Your State

Medicaid generally pays for GLP-1 drugs used for an FDA-approved purpose other than weight loss.¹ Paying for Wegovy, Zepbound or Foundayo for weight loss in adults is each state's choice.^{1, 2} Ozempic, Mounjaro and Trulicity are approved, with diet and exercise, for type 2 diabetes. With diet and more activity, Wegovy is approved to lower heart attack and stroke risk in adults with established cardiovascular disease and obesity or overweight, and Zepbound for moderate to severe obstructive sleep apnea in adults with obesity.^{3, 4, 5, 6, 7} Your state's drug list, its criteria and prior authorization (the program's approval before the pharmacy fills the prescription) still apply.

As of October 3, 2026, we confirmed 10 states where Medicaid still covers GLP-1s for weight loss, each with its own rules: Delaware, Kansas, Michigan, Minnesota, Mississippi, Missouri, North Carolina, Tennessee, Virginia and Wisconsin. Utah, Massachusetts and Rhode Island stopped during 2026.^{8, 9, 10, 11} We checked the 13 states that KFF, a health policy research group, counted as covering in January 2026, plus 11 others, but not every state, so your state's current drug list has the final word.

Three things decide your answer:

1. What the drug is prescribed for. Weight loss is the use a state may refuse. See how each drug and use is handled.
2. Your state. The 10 states and their criteria are in a table below, followed by what we found for other states, including Florida, Texas, Colorado and New York.
3. Who runs your drug benefit. It is either the state itself (fee-for-service) or a Medicaid health plan, and in some states a plan applies its own criteria.¹² Here is how to check, often with one phone call.

Not in one of the 10 states? Medicaid most likely won't pay for weight loss where you live; see what it may still cover, and your other options.⁸ Already turned down? Go to appeals and fair hearings. Have Medicare too? Your drugs come through Medicare instead; see what that changes.¹³ Asking for someone under 21? Medicaid has a separate rule for children.¹⁴

The reason on the prescription decides what Medicaid pays for

Federal Medicaid law lets states exclude or restrict drugs "when used for" weight loss and require prior authorization for any drug. States can also refuse a use that is not a "medically accepted indication": a use FDA approved, or one backed by the drug references named in the law.²

Every state's Medicaid program covers prescription drugs.¹⁵ KFF notes that covering GLP-1s for diabetes, cardiovascular disease and sleep apnea is required, while covering them for obesity is optional.¹ So the same drug can be paid for one person and refused for another:

• Ozempic (semaglutide), Mounjaro (tirzepatide) and Trulicity (dulaglutide) are approved, along with diet and exercise, to control blood sugar in type 2 diabetes. Each is also approved to lower the risk of heart attack, stroke or cardiovascular death in certain adults with type 2 diabetes. Ozempic also has a kidney use for adults with type 2 diabetes and chronic kidney disease. None is approved for weight loss, so states can refuse that use.^{2, 3, 4, 5}
• Wegovy (semaglutide) is approved, with a reduced-calorie diet and more physical activity, to reduce the chance of a heart attack, a stroke or death from cardiovascular causes in adults who have established cardiovascular disease and obesity or overweight. The injection is also approved for adults with MASH (metabolic dysfunction-associated steatohepatitis, formerly called NASH), a form of fatty liver disease with inflammation and liver damage that can lead to scarring. That use covers moderate to advanced scarring (stage F2 or F3) without cirrhosis. FDA gave it accelerated approval, so keeping it may depend on a confirmatory trial.^{6, 16}
• Zepbound (tirzepatide) is approved, with the same diet and activity, for moderate to severe obstructive sleep apnea in adults with obesity.⁷
• Wegovy (injection or tablets), Zepbound and Foundayo (orforglipron, a daily tablet) are approved, with that diet and activity, to help adults lose excess weight and keep it off. The approval covers adults with obesity, or with overweight plus at least one weight-related condition. Medicaid pays for this use only where a state chooses to.^{1, 6, 7, 17}

States that stopped paying for weight loss still handle the other uses. California takes prior authorization requests for Wegovy's heart use and Zepbound's sleep apnea use. It also pays for the diabetes drugs, and for Wegovy for MASH without cirrhosis, if the prescriber includes a diagnosis code.¹⁸

MassHealth in Massachusetts covers these drugs with prior authorization for a body mass index (BMI) over 27 with established cardiovascular disease, for MASH, and for a BMI of 30 or more with moderate to severe obstructive sleep apnea.¹⁰ MassHealth says any drug used off-label for weight loss is not payable.¹⁰

BMI numbers. The Zepbound and Foundayo trials counted a BMI of 30 or more as obesity, and overweight as a BMI from 27 up to 30 with a weight-related condition. Several states in the table below use the same cutoffs.^{7, 17} Wegovy and Ozempic are both semaglutide, and Zepbound and Mounjaro are both tirzepatide, so the brand name tells you which approved uses apply.

Prediabetes or PCOS. Prediabetes is not type 2 diabetes, so it does not meet diabetes-drug criteria such as Pennsylvania's. Where a state covers weight loss, it can count as the weight-related condition; Kansas and Missouri name it.^{19, 20, 21} None of the six drugs this page covers is approved for polycystic ovary syndrome (PCOS), but Kansas's criteria list PCOS among the weight-related conditions that count with a BMI of 27 or more.^{3, 4, 5, 6, 7, 17, 20}

If none of these fits you. A GLP-1 would be off-label for you (a use outside FDA's approval), and states can refuse to pay for it.² Ask your own doctor, ideally one who takes Medicaid, before turning to an online seller; PlexusDx, this page's publisher, sells GLP-1 treatment online but is not open to Medicaid enrollees. We cover GLP-1 options below these BMI levels on a separate page.

Each of these approved uses depends on a diagnosis in your medical records, and states look for it on claims. Mississippi's automatic approval reads the obesity diagnosis code on the pharmacy claim, and Texas looks for diagnoses in past medical and pharmacy claims.^{22, 23, 24} Before starting any of these drugs, read the label facts below.

Ten states where Medicaid still pays for weight loss

Each row links the state's own document as we read it on October 3, 2026. Delaware's list takes effect on October 5.

"Approval" means prior authorization (Virginia calls it service authorization), and "a condition" means a weight-related condition, such as high blood pressure. Preferred drugs are the ones a state's list favors, though in these 10 states even they come with criteria. A non-preferred drug usually takes more, such as two preferred drugs tried first in Delaware, and it can cost more (step 5 of checking your list).¹² Other details that can matter:

• Extra conditions. In Michigan, the prescriber must attest that the drug is being used only to avoid the need for bariatric (weight-loss) surgery. In Virginia, the prescriber must attest that the patient's obesity is "disabling and life threatening."^{26, 31} Mississippi's automatic check also requires no recent pregnancy diagnosis and no GLP-1, Imcivree or Xenical claim in the past month; requests that miss it, such as for people who are overweight with a condition, anyone under 18, people with both Medicare and Medicaid, or claims without a diagnosis code, go to manual review.²²
• Health plans. KFF's count describes fee-for-service rules. Delaware says its health plans use their own criteria, while North Carolina bars its plans from adding criteria for this drug class.^{1, 12, 28} Michigan's row comes from the shared list its Medicaid health plans use; we did not find its fee-for-service criteria, so fee-for-service members there should ask the state.²⁶
• Liraglutide. Delaware, Kansas, Michigan, Minnesota, North Carolina, Tennessee and Virginia also list liraglutide (Saxenda or its generic), a daily GLP-1 injection. It is approved for weight management in adults, and in children 12 and older who have obesity and weigh more than 60 kg (about 132 pounds).^{12, 25, 26, 27, 28, 30, 31, 34} It carries the same boxed warning about thyroid C-cell tumors; this page does not summarize the rest of its label, so review it with your prescriber.³⁴

In these states, a prescriber enrolled in your state's Medicaid program sends the request with your BMI and records, and the program must respond within 24 hours.^{2, 35} See what the request has to show and how to appeal a no.

If your state isn't in the table

For weight loss, plan on Medicaid not paying unless your state's drug list shows Wegovy, Zepbound or Foundayo for weight management; one call to your plan or state agency can confirm it (see how to check). KFF's January 2026 data file lists the other 37 states and Washington, D.C. as not covering GLP-1s for obesity under fee-for-service rules.⁸ As of September 29, 2026, CMS's BALANCE page named no participating state, though Indiana has announced it will join (see BALANCE).^{36, 37} What you can still do is in the next section.

Three of KFF's 13 states ended coverage for weight loss during 2026. Each still covers or considers GLP-1s for other approved uses:

• Utah stopped paying for weight loss in its fee-for-service program on June 30, 2026. It still covers GLP-1s for other FDA-approved uses, including lowering heart attack and stroke risk, MASH and severe obstructive sleep apnea.⁹
• Massachusetts (MassHealth) stopped on July 3, 2026, and reviews requests for members under 21 under the children's rule.¹⁰
• Rhode Island stopped on October 1, 2026, for GLP-1s including Foundayo, Wegovy and Zepbound when prescribed only for weight loss. Anyone continuing for another use needs a new prior authorization.¹¹

California and Pennsylvania ended Medicaid coverage of GLP-1s for weight loss on January 1, 2026, according to their own notices; for California's rules on the other uses, see how each drug and use is handled.^{18, 19} Pennsylvania's criteria, updated March 2, 2026, cover the other uses with prior authorization, such as moderate to severe sleep apnea with a BMI of 35 or more or heart risk with a BMI of 27 or more plus a past heart attack, stroke or qualifying peripheral artery disease.³⁸ KFF counts New Hampshire and South Carolina among the states that also dropped it after October 2025. A notice from one New Hampshire Medicaid health plan gives January 1, 2026 as its date, and we found no South Carolina document.^{1, 39}

Seven states that were not on KFF's list:

• Florida. Its October 1, 2026 drug list includes Mounjaro, Ozempic and Trulicity among its diabetes drugs, each with clinical prior authorization. We did not find Wegovy, Zepbound or Foundayo on it, and KFF lists Florida as not covering GLP-1s for obesity.^{8, 40} A drug missing from the list can still be requested through prior authorization for a use other than weight loss, such as the heart, liver or sleep apnea uses above.^{2, 41}
• Texas. KFF lists Texas as covering no GLP-1 for obesity but at least one other weight-loss medicine (see medicines that aren't GLP-1s).^{1, 8} Its diabetes GLP-1s need a type 2 diabetes diagnosis in the past 365 days and, with exceptions, at least 14 days in a row of an oral diabetes drug in that time.⁴² Wegovy is covered from age 45 for cardiovascular disease with obesity or overweight.²³ From age 18, the injection is covered for MASH (stage F2 or F3, no cirrhosis) confirmed in the past 180 days, and Zepbound for moderate to severe sleep apnea with obesity and an apnea-hypopnea index of at least 15 (breathing pauses or shallow breaths per hour of sleep).^{23, 24}
• Colorado. Health First Colorado says it does not cover weight-loss drugs "for any reason."⁴³ Its page does not say how it treats the other approved uses above, so ask the program if one applies to you.
• New York. NYRx, the state's Medicaid drug program, says it covers FDA-approved drugs used for Medicaid-approved reasons. It excludes them when prescribed for weight loss, Wegovy included, and covers Ozempic and Mounjaro for diabetes.⁴⁴ Its drug list, revised September 14, 2026, approves Wegovy only for confirmed cardiovascular disease and Zepbound only for confirmed obstructive sleep apnea, each with a BMI of 40 or more and lifestyle changes, and at most two treatment attempts per lifetime.⁴⁵
• Ohio. Its rule excludes obesity drugs, even through prior authorization.⁴⁶ Its October 1, 2026 drug list for fee-for-service and health plans covers Wegovy with prior authorization for MASH (stage F2 or F3, no cirrhosis) or, without diabetes, for a BMI of 27 or more plus a past heart attack, stroke or symptomatic peripheral artery disease; we found no Zepbound on it.⁴⁷
• Kentucky. Its rule excludes weight-loss drugs unless its drug list covers them, and its September 2026 list does not include Wegovy, Zepbound or Foundayo.^{48, 49} Its criteria allow Wegovy from age 45 for a past heart attack, stroke or symptomatic peripheral artery disease with a BMI of 27 or more, and the injection from age 18 for MASH (stage F2 or F3, no cirrhosis), neither for people with type 2 diabetes.⁵⁰ Its Zepbound criteria cover moderate to severe sleep apnea with a BMI of 30 or more and exclude anyone with a history of diabetes.⁵¹
• Washington. Apple Health does not cover drugs prescribed for weight loss, though an exception for a noncovered drug can be requested.⁵² Its policies cover Wegovy for established cardiovascular disease with a BMI of 27 or more or for MASH (stage F2 or F3, no cirrhosis), and Zepbound for moderate to severe sleep apnea with a BMI over 30, all for people without diabetes.^{53, 54}

When your state won't pay for weight loss

These routes are for people whose state excludes weight-loss use. They also fit people who meet a drug's FDA-approved use but not their state's stricter rules, such as Michigan's and Virginia's higher BMI cutoffs.^{26, 31} Routes where Medicaid or Medicare may pay come first. If you don't fit any of the approved uses above, start with your own doctor instead.

Another approved use. Your records may show type 2 diabetes, or established cardiovascular disease with obesity or overweight. They may show MASH with moderate to advanced scarring (stage F2 or F3) but not cirrhosis, or moderate to severe obstructive sleep apnea with obesity. If so, ask your prescriber whether a request under that use meets your state's criteria, which can be stricter than the label (see the uses above).

A weight-loss medicine that isn't a GLP-1. In January 2026, KFF found seven states that covered at least one weight-loss drug but no GLP-1 for obesity: Connecticut, Louisiana, New Hampshire, New Mexico, North Dakota, Pennsylvania and Texas.¹ Elsewhere, ask whether your list covers any. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says side effects differ by medicine; most are mild, but serious ones can occur, and experts worry that in some cases they outweigh the benefits. It also says never to take a weight-management medicine during pregnancy or while planning one, and that these medicines are not recommended while breastfeeding, so go over the label warnings for any medicine on your state's list with your prescriber.⁵⁵

Medicare and Medicaid together. If you have both, a Medicare drug plan covers your prescriptions instead of Medicaid. Medicaid may still pay for a drug Medicare does not cover in certain situations.¹³ For weight reduction, Medicare's temporary GLP-1 Bridge covers Wegovy (injection or tablet), Foundayo and the Zepbound KwikPen for a $50 copay per monthly supply through December 31, 2027. It is for adults with Part D coverage who meet its BMI-based criteria and get prior authorization, and Extra Help (Medicare's drug-cost help for people with limited means), which people with both programs get automatically, does not lower the $50.^{13, 56, 57}

People who already get a GLP-1 through their Part D plan cannot use the Bridge. Neither can people with type 2 diabetes, moderate to severe obstructive sleep apnea, or MASH with moderate to advanced scarring (stage F2 or F3) but not cirrhosis; see how the Bridge works.^{57, 58}

BALANCE. If your state joins this federal model, coverage could open under its criteria; ask your state agency whether it will join.

Paying cash for an FDA-approved drug. Lilly's and Novo Nordisk's copay cards for Zepbound and Wegovy exclude anyone enrolled in Medicaid.^{59, 60, 61} Their self-pay prices are a separate route: people with Medicaid can use them if they pay out of pocket, have a prescription for a use on the drug's label and bill no insurance.^{59, 61, 62}

Our cost guide lists every drugmaker's current cash prices and their conditions and which offers each kind of coverage can use, and Foundayo has its own cost page. KFF says buying directly from drugmakers will likely still be too expensive for people on Medicaid, who must have a low income to qualify.¹ Read the label facts below before you choose a drug.

Compounded drugs. Compounded semaglutide and tirzepatide, made by compounding pharmacies, lack FDA approval, and FDA does not check them for safety, effectiveness or quality before sale. In FDA's words, compounded drugs "should only be used in patients whose medical needs cannot be met by an FDA-approved drug." Its guidance adds that a lower price is not enough to justify copying an approved drug.^{63, 64} A Medicaid denial is a cost problem rather than a medical one, so by FDA's test it does not justify switching to a compounded drug.

FDA has received side-effect reports for compounded semaglutide and tirzepatide, including hospital cases that may be related to dosing errors with compounded semaglutide injections, and says reports are likely underreported because most compounding pharmacies, those that are not outsourcing facilities, need not file them. Many resemble the approved drugs' side effects, so the label facts below apply here too.⁶³ If a prescriber suggests a compounded drug, run the checks in our provider guide first.

Your own doctor or a health center. If none of these routes fits, your own doctor is the best next step. If you don't have one, federally funded health centers serve everyone, even people who cannot pay, and adjust their fees based on income and family size. HRSA's Find a Health Center tool lists them.⁶⁵

Label facts that can change which drug or route fits you

If your state's list prefers one GLP-1, or you are weighing a covered use against paying cash, go over these facts with your prescriber. Each applies to all six drugs unless one is named.^{3, 4, 5, 6, 7, 17}

The boxed warning. All six labels warn of thyroid C-cell tumors and rule out anyone with a personal or family history of medullary thyroid carcinoma (MTC), a thyroid cancer, or with multiple endocrine neoplasia syndrome type 2 (MEN 2). Semaglutide, tirzepatide and dulaglutide caused these tumors in rodents. Orforglipron, the drug in Foundayo, does not act on the GLP-1 receptor in rats or mice, so those studies could not show whether it causes these tumors. It does act on the human receptor, and its label says the human relevance of the rodent tumors has not been determined.¹⁷ Whether any of the six causes them in people is unknown; report a neck lump, hoarseness, trouble swallowing or shortness of breath.

Allergies and other conditions. A serious allergic reaction to the drug or its ingredients rules it out. For a severe rash, fainting, a racing heart, trouble breathing or swallowing, or swelling of the face, lips, tongue or throat, stop the drug and get medical help right away. None is recommended with severe gastroparesis (very slow stomach emptying), nor Foundayo with severe liver impairment; the Wegovy and Foundayo guides also ask about kidney problems.^{6, 17}

Pancreas, gallbladder and fluid loss. Tell your prescriber about any pancreas problem, past or present. Severe stomach pain that won't go away, sometimes spreading to the back, may be pancreatitis, which has been fatal: stop the drug and phone your prescriber right away. Phone right away, too, for clay-colored stools, yellow skin or eyes, fever or upper stomach pain, which can mean gallbladder problems (all six labels report them more often than with placebo).^{3, 4, 5, 6, 7, 17} Nausea, vomiting or diarrhea that won't stop also needs a call right away. Drink fluids, since dehydration can injure the kidneys, sometimes enough to need dialysis, and tell your prescriber about stomach problems that are severe or won't go away.

Insulin and diabetes pills. With insulin or a sulfonylurea (a diabetes pill), low blood sugar is more likely, so watch for shakiness, sweating, confusion or a fast heartbeat. The Zepbound, Wegovy and Foundayo labels note it in adults who don't have type 2 diabetes, too. With type 2 diabetes, report vision changes, since the labels warn about diabetic eye complications.^{6, 7, 17}

Mixing medicines. The Zepbound, Wegovy and Foundayo labels advise against taking another GLP-1 drug with them, which would include compounded semaglutide or tirzepatide. All six slow stomach emptying, which can change how pills are absorbed; the Zepbound and Mounjaro labels name warfarin. Wegovy's label reports levothyroxine (thyroid hormone) levels about a third higher with the semaglutide tablet in a study. Foundayo's label says to avoid some medicines that strongly block or speed up a liver enzyme called CYP3A4 (ritonavir is its example) and limits simvastatin.^{4, 6, 7, 17}

Pregnancy. All six labels warn that these drugs may harm an unborn baby. For Mounjaro, Ozempic and Trulicity that warning rests on animal studies, and their guides say it is not known whether they do.^{3, 4, 5, 6, 7, 17}

• Zepbound, Foundayo and Wegovy (weight or heart use): stop when a pregnancy is recognized.^{6, 7, 17}
• Mounjaro, Ozempic, Trulicity and Wegovy (MASH): their labels allow use in pregnancy only if the benefit justifies the risk, so call your prescriber rather than stopping alone.^{3, 4, 5, 6}
• Planning a pregnancy: the Wegovy and Ozempic labels say to stop at least 2 months before (for MASH, Wegovy's says so when the risk outweighs the benefit), so plan the timing with your prescriber.^{3, 6}
• Breastfeeding: Wegovy tablets and Foundayo are not recommended.^{6, 17}

Birth-control pills. Zepbound and Mounjaro can make them work less well. For 4 weeks after the first dose and after every dose increase, switch to another kind of birth control or add condoms or another barrier method. Foundayo's label says 30 days and advises effective birth control throughout.^{4, 7, 17}

Tablets, pens and procedures. Wegovy tablets have strict empty-stomach rules; Foundayo does not. Never share a Zepbound or Mounjaro KwikPen, a Wegovy FlexTouch pen or an Ozempic pen, even with a new needle, because shared pens spread infections. Before a procedure with anesthesia or deep sedation, tell every doctor and dentist involved that you take the drug, since food or liquid can rarely get into the lungs. Wegovy can also raise heart rate.^{3, 4, 6, 7, 17}

Each Medication Guide lists more warnings and, for an overdose, says to call your prescriber or Poison Help (1-800-222-1222) right away or go to the nearest emergency room.

Finding your state's drug list and criteria

The quickest check is a phone call to your health plan's member services, or to your state Medicaid agency if you are not in a plan. Ask three things: whether Wegovy, Zepbound or Foundayo is covered for weight management for you, what the criteria are, and whether you are in fee-for-service or a health plan. Medicaid.gov's state contact page links each state's agency, the office to contact about a claim or to find a provider who takes Medicaid.⁶⁶ To check the documents yourself:

1. Find out who manages your prescriptions. It matters: Delaware's criteria are for fee-for-service members, and its plan members go by their plan's criteria.¹²
2. Open the list that applies to you. Fee-for-service members use the state's preferred drug list. Health plans may publish their own; Michigan's plans share one common list.²⁶ The table above links each covering state's document.
3. Read the drug's status. Preferred and non-preferred are explained under the table. A "DR," or diagnosis restriction, means the drug is paid for only with certain diagnoses; Wisconsin marks its diabetes GLP-1s this way.³²
4. Find the criteria. Look for the drug class's criteria document or request form; the table links the ones we found. If you cannot find them, ask your plan or the state's pharmacy program.
5. Know what you would pay. If your income is at or below 150% of the federal poverty level, copays are limited to nominal (small) amounts. Above that, a non-preferred drug can cost up to 20% of its price, and children and pregnant women are exempt from most out-of-pocket costs.⁶⁷ New York charges $1 or $3 for most prescriptions, and Colorado charges nothing.^{43, 44}

What a prior authorization request has to show

A prescriber enrolled in your state's Medicaid program. Federal rules require states to enroll the physicians and other professionals who order or refer services under the state's Medicaid plan.³⁵ New York spells this out for prescriptions: a Medicaid-enrolled provider writes it and a Medicaid-enrolled pharmacy fills it.⁴⁴ A self-pay program, such as PlexusDx's (see the end of this section), does not bill Medicaid at all.

If your prescriber is not enrolled, ask your plan or state agency to help you find one who is.⁶⁶ If you are weighing an online prescriber, ask before you pay whether they are enrolled in your state's Medicaid program; the checks in our provider guide show how to confirm that the prescriber and the pharmacy are licensed where you live.

Records that match the criteria. Beyond the BMI cutoffs in the table, expect to need a recent weight and BMI; North Carolina wants them measured within 45 days of the request. You may also need proof of diet and activity changes. Minnesota asks for documentation, Kansas for lifestyle steps in the treatment plan, and Wisconsin for the member's agreement to a reduced-calorie diet and more activity.^{20, 27, 29, 33} For a preferred diabetes GLP-1, Pennsylvania accepts a diabetes diagnosis or use of certain other diabetes drugs within the past 120 days.¹⁹

Renewals. Approvals expire. Virginia approves 6 months at a time and renews only after at least 5% weight loss, and Minnesota also asks for 5%. Kansas approves Wegovy and Zepbound for 28 weeks. It renews them for adults who lost 5% of their starting weight by week 12, or 10% by week 28, and kept it off.^{20, 27, 31} Wisconsin approves up to 183 days and renews only if your BMI is lower than when you started.³³

Timing. Federal law requires a response to a prior authorization request within 24 hours, and Medicaid health plans must follow the same rule.^{2, 68} If you hear nothing after a day, ask your prescriber's office to check on it. A separate federal rule requiring at least a 72-hour emergency supply of a covered drug does not apply to drugs used for weight loss.²

Paying while you wait. If you want Medicaid to pay, ask your plan or state agency before you buy the drug yourself while a request is pending. New York, for example, warns that if you pay out of pocket instead of waiting, you may not be paid back.⁴⁴

About PlexusDx, which publishes this page. Its compounded GLP-1 programs are the self-pay kind described above, as its Terms of Service set out: as of October 19, 2026, they are not billed to Medicaid or any insurance plan, so Medicaid pays nothing toward them. PlexusDx does not accept anyone enrolled in Medicaid, in any state, even as a self-pay patient. If you have Medicaid, its programs are not an option for you, whether or not your state has turned down a GLP-1 request. If you are not enrolled in Medicaid, our provider guide sets out who PlexusDx's programs are for, what the intake asks and how Lone Star says its physicians decide when a compounded drug is warranted.

Appealing a denial and asking for a fair hearing

Start with the notice. A health plan's denial notice must give its reasons and explain how to appeal, including how to ask for a fast appeal. It must also tell you that you can get free copies of the records and medical-necessity criteria behind the decision, so ask for them.⁶⁹ A state's notice must likewise give specific reasons and explain your right to a hearing.⁷⁰

Check whether the denial turned on something the criteria ask for, such as the diagnosis code California needs on a diabetes claim, a BMI measured within North Carolina's 45 days or Minnesota's diet-and-activity records. If so, ask your prescriber whether to resend the request with what was missing or to appeal.^{18, 27, 29} Where the state excludes weight loss, as Colorado and New York do, you can still ask for a hearing if you think the program erred, but its rules leave weight-loss use out, so a request for another approved use, or the options above, is the realistic next step.^{43, 44, 71} For someone under 21, see the children's rule.

In a Medicaid health plan. You have 60 days from the date on the plan's notice to appeal to the plan, by phone or in writing. Where state law allows, your prescriber or another representative can file for you with your written consent.⁷² The plan must decide within 30 days at most, or within 72 hours for an expedited appeal. Either deadline can be extended by up to 14 days in some cases.⁷³ An expedited appeal applies when your prescriber indicates, or the plan agrees, that waiting could seriously jeopardize your life, health or ability to regain maximum function.⁷⁴

If the plan upholds the denial, you can ask the state for a fair hearing. Your state sets the window, which is 90 to 120 days from the plan's decision notice.^{72, 73} If the plan misses its deadline or its notice leaves out what the rules require, you can go straight to the fair hearing.⁷²

In fee-for-service. Ask the state for a fair hearing. Every state Medicaid agency must offer one to anyone who believes it acted in error or denied their claim for covered benefits or services.⁷¹ Your notice gives the deadline. Federal rules allow up to 90 days from the date the notice was mailed, a state can allow less, and California generally allows 90, so ask soon. If the usual wait could put your life or health at risk, ask for an expedited hearing in the same request.^{18, 75, 76}

If you have Medicare too. A GLP-1 denial from your Medicare drug plan follows Medicare's rules, not the Medicaid deadlines above, which apply only to a denial from Medicaid itself or a Medicaid health plan. Ask the Medicare plan to reconsider within 65 days of the date on its notice.⁷⁷ Our prior authorization guide's Medicare section covers the later levels.

Part D generally leaves out drugs used for weight loss by law, so an appeal cannot win weight-loss coverage your plan's benefits exclude. The Bridge has no appeals, though a prescriber can resubmit a request with corrected or new information.^{58, 78} A plan that combines Medicare and Medicaid may follow separate federal appeal rules, so read that plan's notice.⁷²

Children and teens on Medicaid

Under federal law, Medicaid's Early and Periodic Screening, Diagnostic and Treatment benefit (EPSDT) applies to members under 21. It covers treatment needed to correct or improve a condition, even if the state's plan does not otherwise cover it.^{1, 14} Massachusetts and Rhode Island say requests for members under 21 are reviewed for medical necessity under EPSDT, and California says weight-loss GLP-1s can still be covered for them with an approved prior authorization.^{10, 11, 18}

The labels are narrower than that. For weight loss in children, only Wegovy injection and Saxenda (liraglutide) are approved, from age 12 with obesity; Saxenda also requires a weight above 60 kg. Mounjaro and Trulicity are approved for type 2 diabetes from age 10.^{4, 5, 6, 34} In teens, Saxenda's label reports low blood sugar even without diabetes, and Wegovy's reports more gallbladder problems than in adults; Saxenda can also raise heart rate and should be stopped if a pregnancy is recognized.^{6, 34}

Zepbound, Foundayo, Wegovy tablets and Wegovy HD (the 7.2 mg dose) are for adults, and Ozempic's safety and effectiveness in children are not established.^{3, 6, 7, 17, 61} Using any of them in a child would be off-label, even where a state's criteria allow it; Missouri's criteria, for example, start at age 12 and prefer Zepbound.²¹

State criteria judge teens by BMI percentile for age and sex rather than adult numbers; Kansas and Missouri ask for the 95th percentile or higher.^{20, 21} Decisions for a child belong with the child's own doctor.

BALANCE: a voluntary federal model your state may join

For adults, no federal rule makes states cover GLP-1s for weight loss.^{1, 2} BALANCE is a voluntary CMS model in which CMS negotiates GLP-1 prices and coverage terms with drugmakers on behalf of state Medicaid agencies, and states can join from May 2026 through January 1, 2027.³⁶ It covers all forms of Mounjaro, Ozempic, Rybelsus (a type 2 diabetes tablet this page does not cover) and Wegovy, plus Foundayo and the Zepbound KwikPen (one pen holds a 28-day supply).^{36, 60} They are included both for uses states already cover, such as type 2 diabetes, and for weight management.³⁶

CMS says coverage depends on which drugmakers and states take part, that patients must meet qualifications including prior authorization, and that the model "will not guarantee coverage for any individual." Indiana's governor announced on July 30, 2026 that the state's Medicaid agency will take part, with eligibility and timing to be announced.^{36, 37}

If your state joins, CMS's terms for states set these coverage criteria, for uses on the drug's FDA label only:⁷⁹

• Your prescriber attests that you have type 2 diabetes, obstructive sleep apnea, or MASH with moderate to advanced scarring (stage F2 or F3) but not cirrhosis.
• Or your prescriber attests that you are making and will keep up lifestyle changes, and you are 18 or older with one of these:
  • A BMI of 35 or more.
  • A BMI of 30 or more with heart failure with preserved ejection fraction (a type of heart failure), uncontrolled high blood pressure, chronic kidney disease stage 3a or higher, moderate or severe sleep apnea, or MASH with that same scarring and no cirrhosis. Uncontrolled here means a top number above 140 or a bottom number above 90 despite two blood pressure medicines.
  • A BMI of 27 or more with prediabetes, a prior heart attack or stroke, or peripheral artery disease with symptoms.

A participating state must use the same criteria in fee-for-service and in its health plans. It cannot add step therapy (trying other treatments first) beyond what the drug's label calls for, lifestyle-based steps included. It may choose looser criteria that stay within the label.⁷⁹

Sources

1. Medicaid Coverage of and Spending on GLP-1s (January 16, 2026), KFF, accessed October 3, 2026.
2. 42 U.S. Code § 1396r-8, Payment for covered outpatient drugs, Legal Information Institute, Cornell Law School, accessed October 3, 2026.
3. OZEMPIC (semaglutide) injection prescribing information and Medication Guide, Novo Nordisk, on DailyMed (National Library of Medicine), accessed October 3, 2026.
4. MOUNJARO (tirzepatide) prescribing information and Medication Guide, Eli Lilly and Company, on DailyMed (National Library of Medicine), accessed October 3, 2026.
5. TRULICITY (dulaglutide) prescribing information and Medication Guide, Eli Lilly and Company, on DailyMed (National Library of Medicine), accessed October 3, 2026.
6. WEGOVY (semaglutide) prescribing information and Medication Guide, Novo Nordisk, on DailyMed (National Library of Medicine), accessed October 3, 2026.
7. ZEPBOUND (tirzepatide) prescribing information and Medication Guide, Eli Lilly and Company, on DailyMed (National Library of Medicine), accessed October 3, 2026.
8. Data file for “13 State Medicaid Programs Covered GLP-1s for Obesity Treatment Under Fee-for-Service as of January 2026”, KFF, accessed October 3, 2026.
9. Medicaid Information Bulletin, May 2026, Utah Department of Health and Human Services, accessed October 3, 2026.
10. Pharmacy Facts #271: MassHealth Changes to Management of Anti-Obesity Medications (March 12, 2026, corrected), MassHealth, Massachusetts Executive Office of Health and Human Services, accessed October 3, 2026.
11. GLP-1 State Budget Guidance (memorandum, August 5, 2026), Rhode Island Executive Office of Health and Human Services, accessed October 3, 2026.
12. 2026 Delaware Medicaid Preferred Drug List (live date October 5, 2026), Delaware Division of Medicaid & Medical Assistance, accessed October 3, 2026.
13. Medicaid, Centers for Medicare & Medicaid Services, Medicare.gov, accessed October 3, 2026.
14. 42 U.S. Code § 1396d, Definitions, Legal Information Institute, Cornell Law School, accessed October 3, 2026.
15. Medicaid Drug Rebate Program (MDRP), Centers for Medicare & Medicaid Services, Medicaid.gov, accessed October 3, 2026.
16. Definition & Facts of NAFLD & NASH, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, accessed October 3, 2026.
17. FOUNDAYO (orforglipron) prescribing information and Medication Guide, Eli Lilly and Company, on DailyMed (National Library of Medicine), accessed October 3, 2026.
18. Changes to GLP-1 Drug Coverage, Effective January 1, 2026, Medi-Cal Rx, California Department of Health Care Services, accessed October 3, 2026.
19. Medical Assistance Bulletin: Coverage Change and Prior Authorization of GLP-1 Receptor Agonists (November 24, 2025), Pennsylvania Department of Human Services, accessed October 3, 2026.
20. Criteria for Prior Authorization: Anti-Obesity Medications (AOMs) (minor updates June 1, 2025), Kansas Department of Health and Environment, Kansas Medical Assistance Program, accessed October 3, 2026.
21. SmartPA Criteria: GLP-1 Receptor Agonists Indicated for Obesity PDL Edit (revised January 29, 2026), MO HealthNet Division, Missouri Department of Social Services, accessed October 3, 2026.
22. Provider Education: Instructions for Prescribing Select Anti-Obesity Agents (July 1, 2026), Mississippi Division of Medicaid, read October 3, 2026. The notice was no longer on the Division's website on October 19, 2026, after the Division rebuilt its site.
23. Texas Prior Authorization Program Clinical Criteria: Wegovy (Semaglutide) (May 8, 2026), Texas Prior Authorization Program (Acentra Health), for Texas Medicaid's Vendor Drug Program, accessed October 3, 2026.
24. Texas Prior Authorization Program Clinical Criteria: Zepbound (Tirzepatide) (May 8, 2026), Texas Prior Authorization Program (Acentra Health), for Texas Medicaid's Vendor Drug Program, accessed October 3, 2026.
25. Kansas Medicaid Preferred Drug List (updated August 1, 2026), Kansas Department of Health and Environment, accessed October 3, 2026.
26. MHP Common Formulary Prior Authorization Criteria (effective October 1, 2026), Michigan Department of Health and Human Services, accessed October 3, 2026.
27. Anti-Obesity Medications: prior authorization criteria (August 2026), Minnesota Department of Human Services, accessed October 3, 2026.
28. North Carolina Medicaid Preferred Drug List, effective October 1, 2026, North Carolina Department of Health and Human Services, accessed October 3, 2026.
29. Outpatient Pharmacy Prior Approval Criteria: GLP1s for Weight Management, Wegovy and Zepbound, NC Medicaid, North Carolina Department of Health and Human Services, accessed October 3, 2026.
30. Prior Authorization Form: Weight Management Agents (revised August 2026), TennCare pharmacy program (Optum Rx), accessed October 3, 2026.
31. Virginia Medicaid Service Authorization Form: Weight-Loss Management (effective July 1, 2026), Virginia Department of Medical Assistance Services, accessed October 3, 2026.
32. Wisconsin Medicaid, BadgerCare Plus Standard, and SeniorCare Preferred Drug List: Quick Reference (effective October 1, 2026), Wisconsin Department of Health Services, ForwardHealth, accessed October 3, 2026.
33. ForwardHealth Online Handbook: Weight Management Agents, Wisconsin Department of Health Services, ForwardHealth, accessed October 3, 2026.
34. SAXENDA (liraglutide) injection prescribing information, Novo Nordisk, on DailyMed (National Library of Medicine), accessed October 3, 2026.
35. 42 CFR § 455.410, Enrollment and screening of providers, Legal Information Institute, Cornell Law School, accessed October 3, 2026.
36. BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
37. Governor Braun Announces State Medicaid Program Will Now Cover GLP-1 Treatments for Eligible Beneficiaries (July 30, 2026), State of Indiana, accessed October 3, 2026.
38. Medical Assistance Bulletin: Prior Authorization of GLP-1 Receptor Agonists, Pharmacy Services (March 2, 2026), Pennsylvania Department of Human Services, Office of Medical Assistance Programs, accessed October 3, 2026.
39. GLP-1 Medications Change in Coverage Effective January 1, 2026, NH Healthy Families, accessed October 3, 2026.
40. Florida Medicaid Preferred Drug List, effective October 1, 2026, Florida Agency for Health Care Administration, accessed October 3, 2026.
41. Pharmacy Prior Authorization Forms, Florida Agency for Health Care Administration, accessed October 3, 2026.
42. Texas Prior Authorization Program Clinical Criteria: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (April 3, 2026), Texas Prior Authorization Program (Health Information Designs), for Texas Medicaid's Vendor Drug Program, accessed October 3, 2026.
43. Health First Colorado Pharmacy Benefits, Colorado Department of Health Care Policy and Financing, accessed October 3, 2026.
44. NYRx Benefits and Coverage, New York State Department of Health (eMedNY), accessed October 3, 2026.
45. NYRx, the Medicaid Drug Program: Preferred Drug List, with the Drug Utilization Review (DUR) Program (revised September 14, 2026), New York State Department of Health, accessed October 3, 2026.
46. Rule 5160-9-03, Pharmacy services: covered drugs and associated limitations (effective February 16, 2024), Ohio Administrative Code, Ohio Department of Medicaid, on codes.ohio.gov, accessed October 3, 2026.
47. Unified Preferred Drug List: Medicaid Fee-for-Service and Managed Care Plans (effective October 1, 2026), Ohio Department of Medicaid, accessed October 3, 2026.
48. 907 KAR 23:010, Outpatient Pharmacy Program, Kentucky Administrative Regulations, Kentucky Legislative Research Commission, accessed October 3, 2026.
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51. Prior Authorization Criteria, Kentucky Medicaid: Zepbound (Tirzepatide) (effective July 1, 2025), Kentucky Medicaid (MedImpact Kentucky portal), accessed October 3, 2026.
52. WAC 182-530-2100, Noncovered: outpatient drugs and pharmaceutical supplies (effective November 21, 2025), Washington Administrative Code, Washington State Legislature, accessed October 3, 2026.
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55. Prescription Medications to Treat Overweight & Obesity, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, accessed October 3, 2026.
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79. BALANCE Model Request for Applications: State Medicaid Agency (March 2026), Centers for Medicare & Medicaid Services, accessed October 3, 2026.

How we made this page

AI tools drafted this page, state table and state entries included, from the documents listed under Sources, all read on October 3, 2026: federal Medicaid law and rules, CMS's BALANCE pages and terms for states, Medicare's Bridge and appeals pages, KFF's January 2026 brief and the data file behind its map, drug lists, criteria, rules and notices from 24 states (one of them a health plan's notice and one a governor's announcement), the FDA labels for the drugs named, and FDA, NIH and HRSA pages. Medicaid drug rules sit in long state PDFs that change during the year; reading KFF's January list against each state's newest document is how the Utah, Massachusetts and Rhode Island changes turned up.

To check the draft, AI reviewers re-opened the sources, compared each quotation and state entry with the document and date it cites, and read every label fact against its label. Before this version they corrected Tennessee's, MassHealth's and Kansas's criteria, added Delaware's liraglutide and Foundayo listings and the rest of Mississippi's automatic-approval checks, and restored a missing clause in Foundayo's boxed warning. Mississippi's July 1 notice was no longer online on October 19, 2026, after the state rebuilt its Medicaid website, so this page cites it as read on October 3. Lists like these can change after October 3, and a page cannot weigh your records the way your own doctor, your plan or a lawyer can.

We did not check every state's documents or individual health plans' drug lists, apart from one plan's notice. The old PlexusDx post at this address grouped states in ways their own documents now contradict and gave wait times and prices we could not source; this version was built from the documents instead.

Statements about PlexusDx are PlexusDx's own, checked against its published Terms of Service and its records as of October 19, 2026, so they carry no source number. Jay Hastings reviewed and approved this version on October 19, 2026. Dr. Asad K. Niazi, MD, MPH, reviewed the medical content on October 17, 2026. He is co-founder and CEO of Lone Star Virtual Health, the company that provides PlexusDx's prescribing clinicians, so he has a business relationship with PlexusDx. PlexusDx sells compounded GLP-1 treatment, so we have a financial interest in this topic. Our editorial policy describes how sources are chosen and dated and how to report an error on this page.