{ "name": "GLP-1 Medicaid Coverage by State: 2026 Tracker", "release_id": "2026-09-28-review-1", "review_as_of": "2026-09-28", "created_on": "2026-09-28", "canonical_page": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/", "release_data_path": "/research/data/medicaid-glp1-coverage/2026-09-28-review-1/", "publisher": "The RX Index Research", "prepared_for_publisher_review": true, "scope": "50 states and the District of Columbia separately. Adult obesity/weight-management coverage findings are bounded by each record's product, program and evidence scope. Under-21 EPSDT and non-obesity indications are separate.", "is_complete_current_coverage_census": false, "record_count": 51, "state_count": 50, "district_count": 1, "coverage_classifications": { "excluded_specific_products": 5, "unresolved": 9, "excluded": 21, "covered_pa": 7, "limited_evidence": 4, "implementation_unverified": 1, "excluded_with_exceptions": 1, "restricted_pa": 2, "scheduled_exclusion": 1 }, "national_coverage_count": null, "national_coverage_count_reason": "Unresolved, product-limited, proposal-stage, and program-specific records cannot support a complete current national count.", "verification_definition": "A review date confirms only the source-backed statement and stated scope. It is not the policy start date, proof of uninterrupted implementation, or verification of every plan and product. Not verified does not mean no coverage or no participation.", "balance_definition": "Reported stage reflects the strongest primary public evidence inspected. Unverified rows were not exhaustively resolved; they do not establish non-participation or absence of a public announcement.", "source_mutability": "Some official links serve changing editions. Edition or rendering disagreements are recorded; they are not silently reconciled.", "reuse": "Free public access intended. Cite publisher, title, release, row, as-of date and primary source. No license grant is asserted by this metadata.", "records": [ { "state": "Alabama", "state_code": "AL", "jurisdiction_type": "state", "current_obesity_status": "Weight-only Wegovy and Zepbound not covered", "coverage_classification": "excluded_specific_products", "program_scope": "Alabama Medicaid pharmacy benefit", "effective_start_date": "PDL file identified as July 2026; original exclusion start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaid.alabama.gov/documents/4.0_Programs/4.3_Pharmacy-DME/4.3.7_Preferred_Drug_List/4.3.7_PDL_Reference_Tool_7-1-26.pdf", "title": "Alabama Medicaid Preferred Drug List Reference Tool", "finding": "Wegovy is non-covered for weight reduction; Zepbound is non-covered for weight reduction without OSA.", "source_version": "July 2026 file identifier", "locator": "Incretin Mimetics footnotes", "checked_on": "2026-09-28", "classification_supported": true, "id": "S001" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "PDL footnotes explicitly exclude Wegovy for weight reduction and Zepbound for weight reduction without OSA. Other-indication authorization is separate.", "verification_limitations": [ "Finding is specific to named products; do not infer a newly verified complete product roster." ], "record_id": "state-alabama", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-alabama", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Alaska", "state_code": "AK", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "A current Alaska obesity-only policy was not established from retrievable primary material. No current yes/no conclusion is made.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-alaska", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-alaska", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Arizona", "state_code": "AZ", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "AHCCCS contractors and fee-for-service programs within AMPM 310-V scope", "effective_start_date": "Current policy version effective: 2025-10-01; original exclusion date not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/310-V.pdf", "title": "AHCCCS Medical Policy Manual 310-V", "finding": "Section J(9) excludes medication used for weight-loss treatment.", "source_version": "2025-10-01", "locator": "PDF p.16, J(9)", "checked_on": "2026-09-28", "classification_supported": true, "id": "S002" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "AMPM 310-V expressly excludes medication used for weight-loss treatment; this is not a conclusion about every other indication.", "verification_limitations": [], "record_id": "state-arizona", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-arizona", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Arkansas", "state_code": "AR", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The targeted Arkansas pharmacy bulletin could not be retrieved reliably. A missing or inaccessible document is not evidence of exclusion.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-arkansas", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-arkansas", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "California", "state_code": "CA", "jurisdiction_type": "state", "current_obesity_status": "Excluded for obesity-only use", "coverage_classification": "excluded", "program_scope": "Medi-Cal Rx outpatient pharmacy; under-21 EPSDT reviewed individually", "effective_start_date": "Exclusion: 2026-01-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/publications/2025.10_A_Important_Update_GLP-1s_Weight_Loss_Not_Covered_Benefit.pdf", "title": "Medi-Cal Rx GLP-1 weight-loss coverage change", "finding": "Saxenda, Wegovy and Zepbound weight-loss coverage ends January 1, 2026; EPSDT and other indications separately reviewed.", "source_version": "2025-10-21", "locator": "pp. 1–2", "checked_on": "2026-09-28", "classification_supported": true, "id": "S003" }, { "url": "https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/04_A_Changes_GLP-1_Drug_Coverage_Wegovy.pdf", "title": "Medi-Cal Rx Changes to GLP-1 Drug Coverage for Wegovy", "finding": "April 2026 update explicitly says Wegovy is not covered for weight loss.", "source_version": "2026-04-06", "locator": "p. 1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S004" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Other indications are separate. An April 2026 notice continues to exclude Wegovy for weight loss; it changes MASH authorization, not obesity coverage.", "verification_limitations": [], "record_id": "state-california", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-california", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Colorado", "state_code": "CO", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The targeted Colorado pharmacy regulation could not be retrieved reliably. No current statewide yes/no conclusion is made.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-colorado", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-colorado", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Connecticut", "state_code": "CT", "jurisdiction_type": "state", "current_obesity_status": "Wegovy weight-only use excluded; reviewed Zepbound route is OSA", "coverage_classification": "excluded_specific_products", "program_scope": "HUSKY Medicaid programs A, C and D; CHIP B is outside the Medicaid count", "effective_start_date": "Wegovy diagnosis rule effective 2025-11-03; Zepbound OSA route 2025-07-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.ctdssmap.com/CTPortal/Information/Get-Download-File?Filename=pb2025_54.pdf&URI=Bulletins/pb2025_54.pdf", "title": "Connecticut Provider Bulletin 2025-54", "finding": "Wegovy is not covered exclusively for weight management; reimbursable diagnoses concern MACE and MASH.", "source_version": "October 2025", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S005" }, { "url": "https://www.ctdssmap.com/CTPortal/Information/Get-Download-File?Filename=pb2025_32.pdf&URI=Bulletins/pb2025_32.pdf", "title": "Connecticut Provider Bulletin 2025-32", "finding": "Zepbound authorization pathway is for obstructive sleep apnea.", "source_version": "June 2025", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S006" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Reviewed bulletins establish non-obesity indication pathways, not a broad adult obesity benefit. Do not reuse the old blanket statement that every GLP-1 requires diabetes.", "verification_limitations": [ "These product-specific bulletins do not independently resolve every marketed obesity product or later formulation." ], "record_id": "state-connecticut", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-connecticut", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Delaware", "state_code": "DE", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "Delaware Medicaid fee-for-service; MCOs use their own criteria", "effective_start_date": "PA form revised April 2026; benefit start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaidpublications.dhss.delaware.gov/docs/Search?Command=Core_Download&EntryId=2017", "title": "DMAP GLP-1 weight management / MASH / MACE prior authorization", "finding": "Adult obesity eligibility includes BMI at least 30, or overweight with a listed comorbidity; PA and supporting records required.", "source_version": "April 2026; page-specific dates April 14 and 20", "locator": "Initial Criteria – Weight Loss", "checked_on": "2026-09-28", "classification_supported": true, "id": "S007" }, { "url": "https://regulations.delaware.gov/register/september2026/final/30%20DE%20Reg%20149%2009-01-26", "title": "Delaware GLP-1 final order, 30 DE Reg. 149", "finding": "Administrative amendment is expressly not intended to change which drugs or coverage criteria apply.", "source_version": "2026-09-01", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S008" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The authorization form includes a weight-loss pathway, not just other indications. September state-plan wording change is administrative, not a termination of coverage.", "verification_limitations": [], "record_id": "state-delaware", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-delaware", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Florida", "state_code": "FL", "jurisdiction_type": "state", "current_obesity_status": "Weight-control medications excluded", "coverage_classification": "excluded", "program_scope": "Florida Medicaid policy; managed-care contracts may specify exceptions", "effective_start_date": "Policy edition December 2017; rule effective 2017-12-24", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://ahca.myflorida.com/content/download/5957/file/59G-4.250_Prescribed_Drug_Coverage_Policy.pdf?version=1", "title": "Florida Medicaid Prescribed Drug Services Coverage Policy", "finding": "Specific exclusions include weight-control medications; EPSDT and managed-care policy scope are separately stated.", "source_version": "December 2017", "locator": "Sections 1.1.2, 4.3 and 5.2", "checked_on": "2026-09-28", "classification_supported": true, "id": "S009" }, { "url": "https://flrules.org/gateway/ruleno.asp?id=59G-4.250", "title": "Florida Administrative Code Rule 59G-4.250", "finding": "Rule registry for prescribed drug services coverage policy.", "source_version": null, "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S010" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Policy names weight-control medications as excluded and separately retains medically necessary under-21 EPSDT review. Check the applicable managed-care contract and pharmacy benefit.", "verification_limitations": [], "record_id": "state-florida", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-florida", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Georgia", "state_code": "GA", "jurisdiction_type": "state", "current_obesity_status": "Adult Saxenda excluded in reviewed FFS criteria; broader status unresolved", "coverage_classification": "limited_evidence", "program_scope": "Georgia Medicaid fee-for-service", "effective_start_date": "Reviewed criteria revised 2021-07-09; current expansion date not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://dch.georgia.gov/document/document/antihyperlipidemics-other-7921/download", "title": "Georgia Medicaid FFS Antihyperlipidemics, Other PA Summary", "finding": "Saxenda is not covered for members age 18 and older under standard criteria; exceptions may be considered.", "source_version": "2021-07-09", "locator": "PDF p.1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S011" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The hosted criteria exclude routine Saxenda coverage at age 18 or older and provide a 12–17 pathway. Exceptions may be requested. This older product-specific policy does not establish every current obesity GLP-1 rule.", "verification_limitations": [ "Current pharmacy manual and current rules for other obesity GLP-1s were not successfully verified." ], "record_id": "state-georgia", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-georgia", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Hawaii", "state_code": "HI", "jurisdiction_type": "state", "current_obesity_status": "Statewide obesity-only status not established", "coverage_classification": "unresolved", "program_scope": "Med-QUEST managed-care formulary directory; not a coverage determination", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [ { "url": "https://medquest.hawaii.gov/en/plans-providers/pharmacy/drug-coverage/mco-formulary-search.html", "title": "Hawaii Med-QUEST — MCO Formulary Search", "finding": "The agency links plan-specific formularies. The directory itself does not determine obesity-only coverage.", "source_version": null, "locator": null, "checked_on": "2026-09-28", "classification_supported": false, "id": "S012" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The official directory links to QUEST plan formularies; it does not establish a statewide obesity-only benefit. Check the actual plan criteria.", "verification_limitations": [ "Current statewide obesity-only benefit was not established from this directory." ], "record_id": "state-hawaii", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-hawaii", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Idaho", "state_code": "ID", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "A drug-list listing or absence would not establish obesity eligibility. A current obesity-specific primary policy was not established.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-idaho", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-idaho", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Illinois", "state_code": "IL", "jurisdiction_type": "state", "current_obesity_status": "Published pharmacy policy excludes weight-loss drugs", "coverage_classification": "excluded", "program_scope": "Illinois HFS pharmacy handbook; individual managed-care/product rules not separately audited", "effective_start_date": "Handbook issued March 2016; exclusion start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/p200.pdf", "title": "Illinois HFS Handbook for Pharmacy Services, Chapter P-200", "finding": "P-206.3 lists weight-loss drugs among non-covered prescription pharmacy items.", "source_version": "March 2016", "locator": "P-206.3; PDF page 32", "checked_on": "2026-09-28", "classification_supported": true, "id": "S013" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The currently hosted handbook lists weight-loss drugs as non-covered. The handbook is old; the verification date is the review date, not a newly issued policy.", "verification_limitations": [ "Older currently hosted handbook; detailed 2026 product-specific and managed-care rules were not fully reverified." ], "record_id": "state-illinois", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-illinois", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Indiana", "state_code": "IN", "jurisdiction_type": "state", "current_obesity_status": "Existing FFS exclusion; expanded benefit not yet verified", "coverage_classification": "implementation_unverified", "program_scope": "Indiana IHCP FFS baseline; BALANCE implementation not established", "effective_start_date": "BALANCE announcement: 2026-07-30; start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.in.gov/medicaid/providers/files/modules/pharmacy-services.pdf", "title": "Indiana IHCP — Pharmacy Services module", "finding": "The FFS module states that agents promoting weight loss are excluded; the publication is older than the BALANCE announcement.", "source_version": "2025-08-12", "locator": "PDF p.16 / printed p.6", "checked_on": "2026-09-28", "classification_supported": true, "id": "S014" } ], "balance_public_status": "Participation announced; launch not verified", "balance_stage": "announced", "balance_last_verified": "2026-09-28", "balance_sources": [ { "url": "https://events.in.gov/event/governor-braun-announces-state-medicaid-program-will-now-cover-glp-1-treatments-for-eligible-beneficiaries", "title": "Indiana governor — GLP-1 Medicaid participation announcement", "finding": "July 30, 2026 release directs FSSA to participate in BALANCE and says eligibility and timing will be announced as the agreement is finalized.", "source_version": "2026-07-30", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S015" } ], "notes": "The published FFS manual excludes weight-loss agents. The governor announced BALANCE participation but left eligibility and timing to a later finalized agreement; an active expanded benefit is not established.", "verification_limitations": [ "No operative BALANCE eligibility criteria, finalized agreement or state-specific coverage start date verified." ], "record_id": "state-indiana", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-indiana", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": "2026-09-28" } }, { "state": "Iowa", "state_code": "IA", "jurisdiction_type": "state", "current_obesity_status": "Excluded for obesity-only use", "coverage_classification": "excluded", "program_scope": "Iowa Medicaid pharmacy PA policy; no separate plan-specific determination", "effective_start_date": "Not established; reviewed form edition: January 2026", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.iowamedicaidpdl.com/content/dam/ffs-medicaid/ia/incretin-mimetics-non-diabetes-pa-npi-0126.pdf", "title": "Iowa Medicaid: incretin mimetics for non-diabetes indications", "finding": "Payment for excluded uses, including weight loss, is denied under Iowa State Plan and IAC 441–78.2(4).", "source_version": "January 2026", "locator": "p. 1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S016" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The current non-diabetes PA form explicitly excludes payment for weight-loss use. Cardiovascular, sleep-apnea and MASH criteria are separate.", "verification_limitations": [], "record_id": "state-iowa", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-iowa", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Kansas", "state_code": "KS", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "Kansas Medicaid anti-obesity PA criteria", "effective_start_date": "Original start not established; criteria update 2025-06-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.kdhe.ks.gov/DocumentCenter/View/407/Anti-Obesity-Medications-PDF", "title": "Kansas KDHE — Anti-Obesity Medications PA Criteria", "finding": "Adult obesity BMI criteria, named GLP-1 agents and exceptions to additional criteria are documented.", "source_version": "2025-06-01", "locator": "PDF pp.1–2; screenshots checked", "checked_on": "2026-09-28", "classification_supported": true, "id": "S017" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The criteria provide an adult obesity pathway for Saxenda, Wegovy and Zepbound. Use product-specific criteria and PDL; do not apply every extra high-cost-agent restriction to every product.", "verification_limitations": [], "record_id": "state-kansas", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-kansas", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Kentucky", "state_code": "KY", "jurisdiction_type": "state", "current_obesity_status": "Weight-loss use excluded unless specifically designated covered", "coverage_classification": "excluded_with_exceptions", "program_scope": "Kentucky Medicaid rule and state pharmacy-benefit criteria", "effective_start_date": "Original exclusion start not established; reviewed current rule", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://apps.legislature.ky.gov/law/kar/titles/907/023/010/", "title": "907 KAR 23:010", "finding": "Excludes weight-loss drugs unless designated covered on the outpatient drug list.", "source_version": null, "locator": "Section 5(2)(a)", "checked_on": "2026-09-28", "classification_supported": true, "id": "S018" }, { "url": "https://kyportal.medimpact.com/sites/default/files/2026-01/wegovy_pa_criteria_1.3.2026.pdf", "title": "Kentucky Medicaid Wegovy PA criteria", "finding": "Reviewed Wegovy indications are cardiovascular risk reduction and MASH.", "source_version": "January 2026", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S019" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "State rule excludes weight-loss drugs unless the outpatient drug list designates coverage. Reviewed Wegovy criteria concern cardiovascular risk reduction or MASH, not a general obesity benefit.", "verification_limitations": [], "record_id": "state-kentucky", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-kentucky", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Louisiana", "state_code": "LA", "jurisdiction_type": "state", "current_obesity_status": "Reviewed Zepbound route requires sleep apnea; obesity-only status unresolved", "coverage_classification": "limited_evidence", "program_scope": "Louisiana Medicaid product-specific clinical authorization", "effective_start_date": "Source implementation date not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://ldh.la.gov/assets/medicaid/PharmPC/12_5_25/4/Zepbound.06052025.pdf", "title": "Louisiana Medicaid Tirzepatide (Zepbound) clinical criteria", "finding": "Initial authorization requires moderate-to-severe obstructive sleep apnea and additional criteria.", "source_version": null, "locator": "PDF p.1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S020" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The reviewed Zepbound criteria require established moderate-to-severe obstructive sleep apnea. This is not proof of an obesity-only benefit or a complete GLP-1 exclusion.", "verification_limitations": [ "Wegovy attachment and current complete obesity-benefit policy were not retrieved successfully." ], "record_id": "state-louisiana", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-louisiana", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Maine", "state_code": "ME", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The targeted MaineCare pharmacy materials were not successfully verified. No current obesity-only yes/no conclusion is made.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-maine", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-maine", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Maryland", "state_code": "MD", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "Maryland Medicaid pharmacy regulation", "effective_start_date": "BALANCE recommendation adopted 2026-05-18; coverage start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://regs.maryland.gov/us/md/exec/comar/10.09.03.05", "title": "COMAR 10.09.03.05 — Limitations", "finding": "Section A(14) excludes weight-control agents, with the opening exception for services specifically covered under Regulation .04.", "source_version": null, "locator": "A(14)", "checked_on": "2026-09-28", "classification_supported": true, "id": "S021" } ], "balance_public_status": "PDAB recommended participation; Medicaid enrollment not verified", "balance_stage": "recommendation", "balance_last_verified": "2026-09-28", "balance_sources": [ { "url": "https://pdab.maryland.gov/cost-reviews/board-selected-drugs/ozempic", "title": "Maryland PDAB Ozempic policy-review final actions", "finding": "The board adopted a non-UPL policy supporting state participation in CMMI models on May 18, 2026.", "source_version": "2026-05-18", "locator": "Non-UPL Final Actions", "checked_on": "2026-09-28", "classification_supported": true, "id": "S022" }, { "url": "https://pdab.maryland.gov/media/1340", "title": "State Participation in CMMI models recommendation", "finding": "The recommendation asks Maryland Medicaid to pursue BALANCE; contacting CMS to formalize participation is a subsequent step.", "source_version": "Draft 2026-05-11", "locator": "Recommendation and Implementation Process", "checked_on": "2026-09-28", "classification_supported": true, "id": "S023" } ], "notes": "The regulation excludes agents used for weight control, subject to specifically covered services in the adjoining regulation; other indications must be checked separately. The May 18 PDAB action is a recommendation, not proof of an executed Medicaid BALANCE agreement.", "verification_limitations": [], "record_id": "state-maryland", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-maryland", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": "2026-09-28" } }, { "state": "Massachusetts", "state_code": "MA", "jurisdiction_type": "state", "current_obesity_status": "Obesity-only coverage ended", "coverage_classification": "excluded", "program_scope": "MassHealth FFS, managed care and other programs named in Pharmacy Facts 276", "effective_start_date": "Exclusion effective: 2026-07-03", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.mass.gov/doc/pharmacy-facts-276-may-13-2026-corrected-0/download", "title": "MassHealth — Pharmacy Facts 276, corrected", "finding": "The corrected notice establishes July 3, 2026 exclusion and lists the affected MassHealth program arrangements.", "source_version": "2026-05-13", "locator": "p.1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S024" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Corrected Pharmacy Facts 276 explicitly ends obesity/overweight-only coverage. Other medically accepted uses and medically necessary under-21 requests are separate.", "verification_limitations": [], "record_id": "state-massachusetts", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-massachusetts", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Michigan", "state_code": "MI", "jurisdiction_type": "state", "current_obesity_status": "Covered with highly restrictive prior authorization", "coverage_classification": "restricted_pa", "program_scope": "Current common-formulary managed-care criteria; separate MDHHS statewide restriction notice", "effective_start_date": "Restriction effective 2026-01-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Assistance-Programs/Medicaid-BPHASA/2025-L-Letters/Numbered-Letter-L-25-73-Pharmacy-Final.pdf", "title": "MDHHS Letter L-25-73", "finding": "Restricts obesity GLP-1 coverage effective January 1, 2026; coverage previously established February 1, 2022.", "source_version": "2025-12-08", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S025" }, { "url": "https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/MHP-Common-Formulary-PDL-PA-Criteria.pdf", "title": "Michigan Medicaid Health Plan common-formulary PA criteria", "finding": "Obesity GLP-1 prior-authorization pathway; multiple preferred non-GLP-1 treatment requirements.", "source_version": null, "locator": "PDF pages 36–38", "checked_on": "2026-09-28", "classification_supported": true, "id": "S026" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Obesity pathway requires extensive prior-treatment criteria and is intended to avert higher-cost bariatric surgery. Do not describe this as a patient aversion to surgery.", "verification_limitations": [ "Parsed edition and rendered page dates differ; no new product roster or uniform FFS criterion is asserted." ], "record_id": "state-michigan", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-michigan", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Minnesota", "state_code": "MN", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "Minnesota Health Care Programs pharmacy criteria", "effective_start_date": "Start date not established; criteria dated August 2026", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/anti-obesity-medications.jsp", "title": "Minnesota DHS — Anti-Obesity Medications", "finding": "August 2026 criteria expressly list Saxenda, Wegovy and Zepbound as covered with prior authorization.", "source_version": "2026-08", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S027" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The reviewed anti-obesity criteria name Saxenda, Wegovy and Zepbound. Product, age, BMI and renewal criteria apply; not every new formulation is established.", "verification_limitations": [], "record_id": "state-minnesota", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-minnesota", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Mississippi", "state_code": "MS", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "Mississippi Division of Medicaid anti-obesity PA criteria", "effective_start_date": "Criteria version: 2026-07-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaid.ms.gov/wp-content/uploads/2026/06/Anti-obesity-Select-Agents-PA-Criteria-07_01_2026-to-Current.V11.pdf", "title": "Mississippi Medicaid — Anti-obesity select agents PA criteria", "finding": "Adult obesity criteria list four agents and BMI criteria; the form distinguishes authorization from payment.", "source_version": "2026-07-01", "locator": "PDF pp.3–4", "checked_on": "2026-09-28", "classification_supported": true, "id": "S028" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The adult PA form names Foundayo, Saxenda, Wegovy and Zepbound. An obesity treatment plan and product-specific approval requirements apply.", "verification_limitations": [], "record_id": "state-mississippi", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-mississippi", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Missouri", "state_code": "MO", "jurisdiction_type": "state", "current_obesity_status": "Existing obesity pathway documented; latest revision adoption not established", "coverage_classification": "limited_evidence", "program_scope": "MO HealthNet pharmacy program", "effective_start_date": "Document lists first implementation 2025-01-09; revision dated 2026-04-23", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://dss.mo.gov/sites/mydss/files/media/file/2026/05/GLP-1%20for%20Obesity%20PDL%204-23-26_1.docx", "title": "MO HealthNet GLP-1 indicated-for-obesity PDL edit", "finding": "Revision of existing obesity criteria; listed first implementation January 9, 2025. Latest revised product preferences are not treated as conclusively implemented.", "source_version": "2026-04-23", "locator": "Header, Executive Summary, Approval Criteria", "checked_on": "2026-09-28", "classification_supported": true, "id": "S029" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Officially posted obesity-specific criteria describe an adult obesity pathway. The revised document is headed Criteria Proposal; adoption of its latest drug roster was not independently established.", "verification_limitations": [ "Document is explicitly headed SmartPA Criteria Proposal; obtain an adopted/current implementation notice before promoting revised product preferences." ], "record_id": "state-missouri", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-missouri", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Montana", "state_code": "MT", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "Montana Medicaid prescription-drug program", "effective_start_date": "Not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaidprovider.mt.gov/manuals/prescriptiondrugprogrammanual", "title": "Montana Medicaid — Prescription Drug Program Manual", "finding": "The noncovered-services list includes drugs for weight reduction.", "source_version": null, "locator": "Noncovered services; lines 354–367", "checked_on": "2026-09-28", "classification_supported": true, "id": "S030" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The program manual identifies drugs used for weight reduction as noncovered. Do not extend this to every GLP-1 indication.", "verification_limitations": [], "record_id": "state-montana", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-montana", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Nebraska", "state_code": "NE", "jurisdiction_type": "state", "current_obesity_status": "Weight-control drugs excluded", "coverage_classification": "excluded", "program_scope": "Nebraska Medicaid; FFS Wegovy PA corroboration", "effective_start_date": "Exclusion start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://dhhs.ne.gov/Pages/Medicaid-Services.aspx", "title": "Nebraska DHHS Medicaid services", "finding": "Weight-control and appetite-suppression drugs/items are listed as not covered.", "source_version": null, "locator": "Physician services", "checked_on": "2026-09-28", "classification_supported": true, "id": "S031" }, { "url": "https://nebraska.fhsc.com/Downloads/NEfaxform_anti-obesity_Wegovy.pdf", "title": "Nebraska FFS Wegovy prior-authorization form", "finding": "Reviewed authorization form concerns cardiovascular risk reduction and MASH.", "source_version": "January 2026", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S032" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "State service guidance excludes drugs/items for weight control or appetite suppression. Reviewed Wegovy authorization form addresses other indications, not a general obesity benefit.", "verification_limitations": [], "record_id": "state-nebraska", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-nebraska", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Nevada", "state_code": "NV", "jurisdiction_type": "state", "current_obesity_status": "Weight-management agents excluded", "coverage_classification": "excluded", "program_scope": "Nevada Medicaid pharmacy policy", "effective_start_date": "Current manual edition 2026-08-03; original exclusion start not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.nevadamedicaid.nv.gov/siteassets/content/resources/adminsupport/manuals/msm/c1200/msm_1200_26_08_03.pdf", "title": "Nevada Medicaid Services Manual, Chapter 1200", "finding": "Section 1203 C excludes agents used for weight management.", "source_version": "2026-08-03 compilation; cited policy page dated 2024-12-02", "locator": "Section 1203 C.1; PDF page 11", "checked_on": "2026-09-28", "classification_supported": true, "id": "S033" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The manual expressly excludes agents used for weight management. Separate non-obesity indication criteria must not be counted as an obesity benefit.", "verification_limitations": [], "record_id": "state-nevada", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-nevada", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "New Hampshire", "state_code": "NH", "jurisdiction_type": "state", "current_obesity_status": "Excluded for obesity-only use", "coverage_classification": "excluded", "program_scope": "New Hampshire Medicaid; notice also directs managed-care providers to their MCO", "effective_start_date": "Exclusion: 2026-01-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://nh.primetherapeutics.com/documents/51139/51630/Notification%2010.09.2025%20-%20GLP-1%20Coverage%20Change/218c7285-7968-9484-a244-859e0741eeba", "title": "NH DHHS change in GLP-1 coverage", "finding": "Solely weight-loss prescriptions no longer covered from January 1, 2026.", "source_version": "2025-10-09", "locator": "p. 1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S034" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Notice excludes prescriptions solely for weight loss; other chronic-condition indications remain separate.", "verification_limitations": [], "record_id": "state-new-hampshire", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-new-hampshire", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "New Jersey", "state_code": "NJ", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only FFS benefit", "coverage_classification": "excluded", "program_scope": "NJ Medicaid / NJ FamilyCare fee-for-service scope in cited regulation", "effective_start_date": "Original start not established; published code compilation June 2025", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://nj.gov/humanservices/notices/documents/rules-and-regulations/NJAC%2010_51%20PHARMACEUTICAL%20SERVICES%20MANUAL.PDF", "title": "NJ Administrative Code — Pharmaceutical Services Manual", "finding": "N.J.A.C. 10:51-1.13(a)(2) excludes antiobesics/anorexiants for obesity except specified lipase inhibitors.", "source_version": "2025-06-16", "locator": "PDF p.29", "checked_on": "2026-09-28", "classification_supported": true, "id": "S035" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The rule excludes antiobesics/anorexiants for obesity, with a lipase-inhibitor exception. That exception is not GLP-1 coverage; managed-care details are not newly determined here.", "verification_limitations": [], "record_id": "state-new-jersey", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-new-jersey", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "New Mexico", "state_code": "NM", "jurisdiction_type": "state", "current_obesity_status": "Named obesity GLP-1s excluded in FFS", "coverage_classification": "excluded", "program_scope": "New Mexico Medicaid fee-for-service; no managed-care-wide finding", "effective_start_date": "Not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.hca.nm.gov/weight-reduction-medications/", "title": "New Mexico HCA: Weight Reduction Medications", "finding": "Official FFS table specifically identifies Saxenda, Wegovy and Zepbound as not covered for weight reduction.", "source_version": "Page metadata last modified 2025-03-04", "locator": "Weight Reduction Medications table", "checked_on": "2026-09-28", "classification_supported": true, "id": "S036" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "HCA lists Saxenda, Wegovy and Zepbound as not covered for weight reduction. Its page also contains older non-GLP-1 drug examples; this review does not endorse that treatment list or infer every formulation.", "verification_limitations": [ "Older page; full contemporary product/formulation and managed-care rules not established." ], "record_id": "state-new-mexico", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-new-mexico", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "New York", "state_code": "NY", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "NYRx Medicaid pharmacy program", "effective_start_date": "Start not established; manual version September 2026", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Policy_Guidelines.pdf", "title": "NYRx — Pharmacy Manual Policy Guidelines", "finding": "September 2026 edition lists weight-loss uses under Drug Coverage Limitations.", "source_version": "2026-09", "locator": "PDF p.30 / printed p.29", "checked_on": "2026-09-28", "classification_supported": true, "id": "S037" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The current pharmacy manual lists drugs used for weight loss as nonreimbursable. Other indications have separate criteria.", "verification_limitations": [], "record_id": "state-new-york", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-new-york", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "North Carolina", "state_code": "NC", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "NC Medicaid Direct and managed care", "effective_start_date": "Reinstated: 2025-12-12", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaid.ncdhhs.gov/blog/2025/12/19/nc-medicaid-reinstitute-coverage-glp-1s-weight-management", "title": "NC Medicaid — GLP-1 weight-management coverage reinstatement", "finding": "December 19 bulletin reinstates obesity coverage effective December 12 in Direct and managed care and includes three named drugs.", "source_version": "2025-12-19", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S038" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The reinstatement includes Wegovy, Zepbound and Saxenda. Wegovy is preferred; the other two have non-preferred authorization requirements.", "verification_limitations": [], "record_id": "state-north-carolina", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-north-carolina", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "North Dakota", "state_code": "ND", "jurisdiction_type": "state", "current_obesity_status": "Narrow medication-induced weight-gain route; general obesity status unresolved", "coverage_classification": "limited_evidence", "program_scope": "North Dakota Medicaid pharmacy manual", "effective_start_date": "Original start and current revision date not established", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.hhs.nd.gov/sites/default/files/documents/pharmacy-provider-manual-exclusion.pdf", "title": "North Dakota Medicaid Pharmacy Provider Manual", "finding": "Limited coverage includes Victoza for antipsychotic-induced weight gain.", "source_version": null, "locator": "PDF p.11, Limited Coverage Categories", "checked_on": "2026-09-28", "classification_supported": true, "id": "S039" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The manual lists Victoza for antipsychotic-induced weight gain separately from its non-GLP-1 weight-loss agents. That exception must not be described as a broad obesity GLP-1 benefit.", "verification_limitations": [ "Current product-specific obesity-only criteria and all program differences remain unresolved." ], "record_id": "state-north-dakota", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-north-dakota", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Ohio", "state_code": "OH", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "Ohio Medicaid and managed-care entities", "effective_start_date": "Rule version: 2024-02-16", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://codes.ohio.gov/ohio-administrative-code/rule-5160-9-03", "title": "Ohio Administrative Code 5160-9-03", "finding": "Section (B)(1) identifies drugs for obesity as noncovered; section (A) includes ODM and managed-care entities.", "source_version": "2024-02-16", "locator": "(A), (B)(1)", "checked_on": "2026-09-28", "classification_supported": true, "id": "S040" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The rule lists drugs for treatment of obesity as noncovered; this is not a finding about other indications or individualized under-21 requests.", "verification_limitations": [], "record_id": "state-ohio", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-ohio", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Oklahoma", "state_code": "OK", "jurisdiction_type": "state", "current_obesity_status": "Weight-only Wegovy and Zepbound not covered under reviewed criteria", "coverage_classification": "excluded_specific_products", "program_scope": "SoonerCare pharmacy clinical authorization", "effective_start_date": "Start date not established; 2026 criteria page", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://oklahoma.gov/ohca/providers/types/pharmacy/prior-authorization/2026/metabolic-disorders.html", "title": "Oklahoma Health Care Authority: Metabolic Disorders PA criteria", "finding": "The published Wegovy and Zepbound pathways do not approve obesity-only use.", "source_version": "2026 page", "locator": "Wegovy and Zepbound sections", "checked_on": "2026-09-28", "classification_supported": true, "id": "S041" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Wegovy criteria require cardiovascular disease or MASH; Zepbound criteria require obstructive sleep apnea. The page explicitly rejects obesity without the respective qualifying condition.", "verification_limitations": [ "Finding is specific to reviewed products; no complete new-formulation census asserted." ], "record_id": "state-oklahoma", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-oklahoma", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Oregon", "state_code": "OR", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The targeted current Oregon guideline and prior-authorization materials were not successfully retrieved. No current yes/no conclusion is made.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-oregon", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-oregon", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Pennsylvania", "state_code": "PA", "jurisdiction_type": "state", "current_obesity_status": "Excluded for obesity-only use", "coverage_classification": "excluded", "program_scope": "Pennsylvania Medical Assistance fee-for-service and managed care", "effective_start_date": "Exclusion: 2026-01-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/docs/publications/documents/forms-and-pubs-omap/mab2025112402.pdf", "title": "Pennsylvania Medical Assistance Bulletin: obesity treatment coverage change", "finding": "Ends GLP-1 obesity/overweight coverage January 1, 2026; applies to FFS and managed care.", "source_version": "2025-11-24", "locator": "pp. 1–3", "checked_on": "2026-09-28", "classification_supported": true, "id": "S042" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Non-GLP-1 obesity drugs remain a separate benefit. GLP-1 use for other medically accepted indications requires its own authorization.", "verification_limitations": [], "record_id": "state-pennsylvania", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-pennsylvania", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Rhode Island", "state_code": "RI", "jurisdiction_type": "state", "current_obesity_status": "Coverage change scheduled; exclusion not yet effective", "coverage_classification": "scheduled_exclusion", "program_scope": "Rhode Island Medicaid provider guidance", "effective_start_date": "Scheduled exclusion: 2026-10-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2026-08/GLP-1%20Change%202026%2010%2001_0.pdf", "title": "Rhode Island EOHHS — GLP-1 State Budget Guidance", "finding": "Notice dated August 5, 2026 schedules weight-loss-only exclusion of four named agents for October 1, 2026; distinguishes other indications and under-21 review.", "source_version": "2026-08-05", "locator": "PDF page 1; visual check completed", "checked_on": "2026-09-28", "classification_supported": true, "id": "S043" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The August 5 notice names Foundayo, Saxenda, Wegovy and Zepbound when used solely for weight loss. Other medically necessary uses require a new PA; under-21 requests receive medical-necessity review.", "verification_limitations": [], "record_id": "state-rhode-island", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-rhode-island", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "South Carolina", "state_code": "SC", "jurisdiction_type": "state", "current_obesity_status": "Obesity GLP-1 removal documented", "coverage_classification": "excluded", "program_scope": "South Carolina Medicaid pharmacy program", "effective_start_date": "PDL removal dated 2025-12-31", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://southcarolina.fhsc.com/downloads/provider/PTMinutes_20251105.pdf", "title": "South Carolina Medicaid P&T minutes, November 5, 2025", "finding": "State Updates announce GLP-1 obesity drugs removed from the PDL December 31, 2025.", "source_version": "2025-11-05", "locator": "State Updates", "checked_on": "2026-09-28", "classification_supported": true, "id": "S044" }, { "url": "https://southcarolina.fhsc.com/downloads/provider/SCRx_PAcriteria_GLP1s.pdf", "title": "South Carolina GLP-1 receptor agonist clinical criteria", "finding": "Reviewed May 2026 document describes diabetes criteria rather than a broad obesity benefit.", "source_version": "2026-05-01", "locator": null, "checked_on": "2026-09-28", "classification_supported": true, "id": "S045" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Official state-update minutes document removal of GLP-1 drugs for obesity from the PDL and separate continuing Wegovy non-obesity use. Current diabetes criteria are not an obesity expansion.", "verification_limitations": [ "Latest September PDL file was not successfully retrieved; no later reinstatement was verified." ], "record_id": "state-south-carolina", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-south-carolina", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "South Dakota", "state_code": "SD", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "South Dakota Medicaid pharmacy services", "effective_start_date": "Start not established; manual updated May 2026", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://dss.sd.gov/docs/medicaid/providers/billingmanuals/Pharmacy/Pharmacy_Services.pdf", "title": "South Dakota Medicaid — Pharmacy Services manual", "finding": "The May 2026 manual excludes drugs used for weight loss in its noncovered-services section.", "source_version": "2026-05", "locator": "PDF p.9", "checked_on": "2026-09-28", "classification_supported": true, "id": "S046" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The noncovered-services list excludes agents used for weight loss. Other medically accepted indications must be evaluated separately.", "verification_limitations": [], "record_id": "state-south-dakota", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-south-dakota", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Tennessee", "state_code": "TN", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "TennCare pharmacy program", "effective_start_date": "Coverage began: 2025-08-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://contenthub-aem.optumrx.com/content/dam/contenthub/onboarding/assets/Tenncare/Obesity-Management-Agents-PA-Form.pdf", "title": "TennCare Weight Management Agents PA Form", "finding": "August 2026 form has an obesity-specific authorization pathway for Wegovy injection, Zepbound single-dose prefilled pen, Saxenda and weight-management liraglutide.", "source_version": "Live link: parsed/rendered revision dates differ", "locator": "pp. 2, 4", "checked_on": "2026-09-28", "classification_supported": true, "id": "S047" }, { "url": "https://contenthub-aem.optumrx.com/content/dam/contenthub/onboarding/assets/Tenncare/Provider-Notice-Obesity-Management-Agents-08-01-25.pdf", "title": "TennCare — Obesity Management Agents coverage notice", "finding": "Notice expressly begins adult obesity-management coverage August 1, 2025 and names Wegovy, Zepbound and Saxenda.", "source_version": "Live link: parsed/rendered revision dates differ", "locator": "PDF p.1", "checked_on": "2026-09-28", "classification_supported": true, "id": "S048" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The reviewed obesity-specific PA form lists Wegovy injection and Zepbound single-dose prefilled pen as preferred. Other formulations and non-preferred agents require their own rules.", "verification_limitations": [ "Parsed PA revision reads August 2026; rendered pages showed April/July 2026. Obesity pathway is consistent, but do not present one definitive downloaded-edition date or expand formulations." ], "record_id": "state-tennessee", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-tennessee", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Texas", "state_code": "TX", "jurisdiction_type": "state", "current_obesity_status": "Reviewed Wegovy criteria exclude obesity-only use", "coverage_classification": "excluded_specific_products", "program_scope": "Texas Medicaid prior-authorization program; criteria do not by themselves confirm NDC formulary coverage", "effective_start_date": "Criteria version: 2026-05-08", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://paxpress-txpa.acentra.com/wegovy.pdf", "title": "Texas Prior Authorization Program: Wegovy clinical criteria", "finding": "Initial requests without cardiovascular disease or MASH are denied under the published decision logic.", "source_version": "2026-05-08", "locator": "PDF p.4, Initial Request", "checked_on": "2026-09-28", "classification_supported": true, "id": "S049" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The Wegovy decision logic requires cardiovascular disease or MASH. Obesity alone does not satisfy it. This review does not establish a complete current GLP-1 product or managed-care roster.", "verification_limitations": [ "Other products and managed-care implementation not fully reverified." ], "record_id": "state-texas", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-texas", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Utah", "state_code": "UT", "jurisdiction_type": "state", "current_obesity_status": "Fee-for-service obesity-only coverage ended", "coverage_classification": "excluded", "program_scope": "Utah Medicaid fee-for-service; managed care not determined here", "effective_start_date": "FFS exclusion: 2026-06-30", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://medicaid-documents.dhhs.utah.gov/Documents%2Fmanuals%2Fpdfs%2FMedicaid+Information+Bulletins%2FTraditional+Medicaid+Program%2F2026%2FMay2026-MIB.pdf", "title": "Utah Medicaid — May 2026 Information Bulletin, 26-45", "finding": "The bulletin expressly says FFS GLP-1 weight-loss coverage ends effective June 30, 2026.", "source_version": "2026-05", "locator": "Section 26-45", "checked_on": "2026-09-28", "classification_supported": true, "id": "S050" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "May 2026 bulletin 26-45 expressly ends FFS weight-loss coverage for Wegovy, Saxenda and Zepbound. It preserves other indications; this is not a statewide managed-care determination.", "verification_limitations": [], "record_id": "state-utah", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-utah", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Vermont", "state_code": "VT", "jurisdiction_type": "state", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The current Vermont PDL extraction did not return the relevant policy text. No current obesity-only classification is asserted.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-vermont", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-vermont", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } }, { "state": "Virginia", "state_code": "VA", "jurisdiction_type": "state", "current_obesity_status": "Covered through a restricted prior-authorization pathway", "coverage_classification": "restricted_pa", "program_scope": "Virginia DMAS pharmacy service-authorization criteria", "effective_start_date": "Form effective: 2026-07-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.virginiamedicaidpharmacyservices.com/provider/external/medicaid/vamps/doc/en-us/VAMPS_SAform_Weight_Loss_Management.pdf", "title": "Virginia DMAS — Weight-Loss Management SA Form", "finding": "Rendered p.3 establishes an obesity GLP-1 pathway with BMI >40 or >37 with specified risk factors, plus other requirements.", "source_version": "2026-07-01", "locator": "PDF p.3; screenshot checked", "checked_on": "2026-09-28", "classification_supported": true, "id": "S051" } ], "balance_public_status": "Evaluation authorized; participation not confirmed", "balance_stage": "evaluation_authorized", "balance_last_verified": "2026-09-28", "balance_sources": [ { "url": "https://budget.lis.virginia.gov/item/2026/2/HB30/Chapter/1/291/", "title": "Virginia enacted budget, Item 291 MMMM", "finding": "Directs evaluation of federal/manufacturer arrangements; BALANCE action is conditional on the department determining it yields the greatest savings. Not evidence of an executed agreement.", "source_version": "2026 enacted budget", "locator": "MMMM.2–5", "checked_on": "2026-09-28", "classification_supported": true, "id": "S052" } ], "notes": "The obesity pathway has high BMI and prior-treatment requirements. The PDF text and rendered product roster differ; this release does not assert a complete current product list.", "verification_limitations": [ "Parsed text includes Foundayo while the rendered roster does not. No complete product roster asserted." ], "record_id": "state-virginia", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-virginia", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": "2026-09-28" } }, { "state": "Washington", "state_code": "WA", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit; exceptions possible", "coverage_classification": "excluded", "program_scope": "Apple Health prescription-drug benefit", "effective_start_date": "Rule version: 2025-11-21", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://app.leg.wa.gov/wac/default.aspx?cite=182-530-2100", "title": "WAC 182-530-2100", "finding": "Weight-loss drugs are excluded under (1)(b)(i); (2) allows exception requests; (3) provides EPSDT review.", "source_version": "2025-11-21", "locator": "(1)(b)(i), (2), (3)", "checked_on": "2026-09-28", "classification_supported": true, "id": "S053" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "An exception-to-rule process and medically necessary EPSDT review for members age 20 and younger are expressly identified.", "verification_limitations": [], "record_id": "state-washington", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-washington", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "West Virginia", "state_code": "WV", "jurisdiction_type": "state", "current_obesity_status": "Excluded from standard obesity-only benefit", "coverage_classification": "excluded", "program_scope": "West Virginia Medicaid pharmacy services", "effective_start_date": "Manual effective: 2024-07-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://bms.wv.gov/media/22021/download?inline=", "title": "West Virginia BMS — Chapter 518, Pharmacy Services", "finding": "Section 518.3 expressly lists weight-loss agents among noncovered services.", "source_version": "2024-07-01", "locator": "PDF p.9, section 518.3", "checked_on": "2026-09-28", "classification_supported": true, "id": "S054" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Chapter 518 lists agents used for weight loss as noncovered. This finding does not exclude the same product for a separately covered indication.", "verification_limitations": [], "record_id": "state-west-virginia", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-west-virginia", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Wisconsin", "state_code": "WI", "jurisdiction_type": "state", "current_obesity_status": "Covered with prior authorization", "coverage_classification": "covered_pa", "program_scope": "ForwardHealth pharmacy benefit (BadgerCare Plus / Wisconsin Medicaid)", "effective_start_date": "Class/criteria change: 2026-07-01", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.forwardhealth.wi.gov/kw/pdf/2026-15.pdf", "title": "ForwardHealth Update 2026-15", "finding": "The July 1 change creates a weight-management class with Foundayo and Zepbound and adult BMI-based PA criteria.", "source_version": "2026-06", "locator": "PDF pp.4–5; screenshots checked", "checked_on": "2026-09-28", "classification_supported": true, "id": "S055" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "Foundayo and Zepbound are preferred weight-management agents, with PA. Wegovy has separate criteria; do not assume all brands or formulations share obesity coverage.", "verification_limitations": [], "record_id": "state-wisconsin", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-wisconsin", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "Wyoming", "state_code": "WY", "jurisdiction_type": "state", "current_obesity_status": "Reviewed Wegovy/Zepbound routes require other indications", "coverage_classification": "excluded_specific_products", "program_scope": "Wyoming Medicaid pharmacy clinical criteria", "effective_start_date": "Criteria last updated: 2026-06-08", "coverage_last_verified": "2026-09-28", "sources": [ { "url": "https://www.wymedicaid.org/content/dam/ffs-medicaid/wy/atcc-060826.pdf", "title": "Wyoming Medicaid Additional Therapeutic Classes with Clinical Criteria", "finding": "Wegovy criteria require cardiovascular disease; Zepbound criteria require obstructive sleep apnea.", "source_version": "2026-06-08", "locator": "PDF p.6", "checked_on": "2026-09-28", "classification_supported": true, "id": "S056" } ], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "The clinical chart requires cardiovascular disease for its Wegovy pathway and obstructive sleep apnea for Zepbound. The broader manual is marked draft; it is not used as definitive proof of a class-wide exclusion.", "verification_limitations": [ "Other product/indication pathways and a finalized general exclusion policy not fully verified." ], "record_id": "state-wyoming", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-wyoming", "as_of": "2026-09-28", "last_verified": { "coverage_finding": "2026-09-28", "balance_finding": null } }, { "state": "District of Columbia", "state_code": "DC", "jurisdiction_type": "district", "current_obesity_status": "Not established in this review", "coverage_classification": "unresolved", "program_scope": "Not established", "effective_start_date": "Not established", "coverage_last_verified": null, "sources": [], "balance_public_status": "Not verified", "balance_stage": "unverified", "balance_last_verified": null, "balance_sources": [], "notes": "A current District obesity-only policy was not established in this review. D.C. is reported separately and is not counted as a state.", "verification_limitations": [ "Current obesity-only coverage classification remains unresolved." ], "record_id": "state-district-of-columbia", "record_url": "https://therxindex.com/research/glp1-medicaid-coverage-by-state/#state-district-of-columbia", "as_of": "2026-09-28", "last_verified": { "coverage_finding": null, "balance_finding": null } } ] }