Medicaid GLP-1 coverage state by state: the 2026 landscape

Medicaid spending on GLP-1 receptor agonists rose from $1 billion in 2019 to nearly $9 billion in 2024, according to KFF — a ninefold increase in five years. Yet as of January 2026, only 13 state Medicaid programs cover GLP-1 drugs for obesity treatment under fee-for-service. Four states (California, New Hampshire, Pennsylvania, and South Carolina) eliminated coverage between October 2025 and January 2026. North Carolina dropped coverage in October 2025 due to a legislative budget stalemate, then reinstated it. Michigan restricted coverage to patients classified as morbidly obese (BMI ≥40).

The coverage contraction comes even as the federal government prepares to launch the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, a CMS initiative that will negotiate GLP-1 pricing and establish standardized coverage criteria for participating state Medicaid agencies beginning in May 2026. States that opt in will receive lower drug prices in exchange for meeting minimum coverage standards.

This guide maps the current Medicaid GLP-1 coverage landscape state by state, explains why coverage is contracting despite rising demand, details the BALANCE Model's potential impact, and identifies what market access teams, state policy analysts, and benefit verification specialists should monitor. It is not medical advice or reimbursement guidance for a specific patient or plan.

Quick answer

Who this is for

• Market access and government affairs teams at GLP-1 manufacturers
• State Medicaid policy analysts and pharmacy directors
• Benefit verification specialists handling Medicaid GLP-1 PA submissions
• Advocacy organizations tracking obesity treatment access
• Prescribers treating Medicaid beneficiaries with obesity or type 2 diabetes

Source standard

Every fact in this guide is sourced from KFF Medicaid GLP-1 analyses, CMS policy documents, state Medicaid bulletins, the Federal Register, and peer-reviewed research dated 2025–2026. Coverage rules change frequently and vary by state, managed care plan, and eligibility category. Always verify current coverage with the specific state Medicaid program or managed care plan.

Why Medicaid GLP-1 coverage is optional and declining

The statutory framework

Under the Medicaid Drug Rebate Program (MDRP), state Medicaid programs must cover nearly all FDA-approved drugs from participating manufacturers for medically accepted indications. However, federal law gives states an explicit option to exclude drugs used for weight loss. This carve-out has existed since the Medicaid Drug Rebate Program was established, and it is the reason obesity GLP-1 coverage varies so dramatically across states.

Coverage for GLP-1 drugs prescribed for type 2 diabetes, cardiovascular risk reduction (Wegovy), and obstructive sleep apnea (Zepbound) is required under MDRP. Only the obesity/weight-loss indication is optional.

The cost driver

Medicaid prescriptions for GLP-1 drugs increased from approximately 1 million in 2019 to over 8 million in 2024, according to KFF. Gross spending rose from $1 billion to almost $9 billion in the same period. Key cost drivers:

• Expanding indications: FDA approvals for obesity (Wegovy 2021, Zepbound 2023), cardiovascular risk reduction (Wegovy 2024), MASH (Wegovy 2025), and obstructive sleep apnea (Zepbound 2024) have broadened the eligible population
• Rising utilization: GLP-1 prescriptions accounted for approximately 1% of all Medicaid prescriptions in 2024, up from 0.01% in 2019
• High per-unit cost: Even with Medicaid best-price rebates, GLP-1 net cost per prescription remains substantial

California's experience illustrates the fiscal pressure. In 2024, Ozempic and Wegovy cost the state's Medicaid program $1.61 billion and accounted for 9.97% of total Medicaid reimbursements — leading the state to exclude GLP-1s for weight loss effective January 1, 2026.

States that cover GLP-1s for obesity treatment (13 states, January 2026)

According to KFF, the following 13 state Medicaid programs covered GLP-1 drugs for obesity treatment under fee-for-service as of January 2026:

All 13 states that cover GLP-1s for obesity impose utilization controls, most commonly prior authorization and BMI requirements, according to KFF's analysis.

States that recently dropped coverage

California (Medi-Cal)

Effective January 1, 2026, Medi-Cal excluded GLP-1 drugs for weight loss. Key details:

• Ozempic and Wegovy cost the state $1.61 billion in 2024, representing nearly 10% of total Medicaid drug spending
• Wegovy is retained for MASH and cardiovascular risk reduction indications
• All GLP-1s remain covered for type 2 diabetes
• Children and young adults under 21 may still receive GLP-1s for obesity through EPSDT requirements

Pennsylvania

Effective January 1, 2026, Pennsylvania Medicaid ended GLP-1 coverage for weight loss in adults 21 and over:

• Pennsylvania DHS issued a Medical Assistance Bulletin (November 24, 2025) formalizing the change
• Saxenda (liraglutide) is no longer covered for any indication
• GLP-1 receptor agonists continue to be covered for medically accepted indications other than overweight/obesity with PA
• Children under 21 retain coverage through EPSDT
• All existing GLP-1 recipients were required to have new PA requests submitted before January 1, 2026

New Hampshire

Effective January 1, 2026, New Hampshire Healthy Families (Centene) no longer covers GLP-1 medications prescribed solely for weight loss. Coverage continues for other chronic health conditions.

South Carolina

BCBS of South Carolina, which administers some Medicaid managed care plans, implemented tighter GLP-1 utilization management effective September 2025, restricting coverage for expanded indications even when FDA-approved.

EPSDT: children under 21 retain coverage

Federal law requires Medicaid to cover all medically necessary treatments for beneficiaries under 21 through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision. This means that even in states where Medicaid has excluded GLP-1s for adult weight loss, children and young adults under 21 with obesity or overweight diagnoses may still receive GLP-1 coverage if deemed medically necessary. Prescribers must submit a PA request documenting medical necessity.

The BALANCE Model: what changes for Medicaid GLP-1 coverage

CMS announced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model as part of the Trump Administration's GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) initiative. Key details:

Structure

• Timeline: Rolling implementation from May 1, 2026 through January 1, 2027; runs through December 2031
• Participation: State Medicaid agencies must opt in by signing a State Agreement with CMS and adopting supplemental rebate agreements (SRAs) with each participating manufacturer
• Manufacturers: Eli Lilly and Novo Nordisk are the initial participating manufacturers, offering lower-priced GLP-1 drugs in exchange for broader coverage

Coverage criteria

The BALANCE Model establishes standardized coverage criteria that participating states must meet:

• States may offer broader coverage but cannot make criteria more restrictive than the model's key terms
• Standardized PA criteria apply equally in both fee-for-service and Medicaid managed care
• The goal is to prevent states from obtaining lower prices while maintaining restrictive access barriers

Medicaid beneficiary eligibility

The model phases in GLP-1 coverage for Medicaid beneficiaries in three groups:

1. Phase 1: Adults with BMI ≥40 (severe obesity) and at least one obesity-related comorbidity
2. Phase 2: Adults with BMI ≥35 and related comorbidities
3. Phase 3: Adults with BMI >35

Impact on current coverage landscape

The BALANCE Model could change the Medicaid GLP-1 coverage calculus in several ways:

• States that dropped coverage may re-enter: Lower negotiated prices could make coverage fiscally viable for states like California and Pennsylvania
• Standardized PA reduces administrative burden: Uniform criteria simplify PA submissions across multiple states
• Price certainty: Multi-year pricing agreements give state budget planners more predictability
• However, opt-in is voluntary: States are not required to participate, and some may choose not to

GLP-1 spending trends in Medicaid

Source: KFF analysis of Medicaid State Drug Utilization Data, 2026.

The growth has been driven primarily by Ozempic and Wegovy (semaglutide) and Mounjaro and Zepbound (tirzepatide), which together account for the vast majority of Medicaid GLP-1 prescriptions and spending.

What access teams should monitor

1. BALANCE Model opt-in timeline: Track which states sign State Agreements with CMS and adopt SRAs. Early opt-in states (May–July 2026) will set the pattern for later adopters.
2. State legislative action: Several states have introduced bills that would require Medicaid to cover anti-obesity medications. Monitor legislative sessions for coverage mandates that could override exclusion decisions.
3. Michigan restriction model: Michigan's morbid-obesity-only threshold (BMI ≥40) may become a template for other states seeking to limit coverage without eliminating it entirely.
4. Rhode Island and Wisconsin: Both states currently cover GLP-1s for obesity but are reportedly considering additional restrictions. Monitor for potential coverage changes.
5. GLP-1 Bridge overlap: The Medicare GLP-1 Bridge demonstration (July 2026–December 2027) runs in parallel to the BALANCE Model. Dually eligible beneficiaries may access GLP-1s through either or both programs.
6. Generic liraglutide impact: As generic liraglutide becomes available, some states may adopt it as a mandatory step-therapy prerequisite before branded semaglutide or tirzepatide — both for T2D and, where covered, for obesity.

Key takeaways

• Only 13 state Medicaid programs covered GLP-1s for obesity treatment under fee-for-service as of January 2026, down from 16 in October 2025.
• California, New Hampshire, Pennsylvania, and South Carolina all dropped coverage between October 2025 and January 2026, citing cost and budget pressure.
• Michigan restricted coverage to morbid obesity (BMI ≥40), and Rhode Island and Wisconsin may follow with additional restrictions.
• All states must continue covering GLP-1s for type 2 diabetes, cardiovascular risk reduction (Wegovy), and other medically accepted indications under the Medicaid Drug Rebate Program.
• Children under 21 retain GLP-1 coverage for obesity through EPSDT, even in states that exclude adult weight-loss coverage.
• The BALANCE Model (launching May 2026) offers lower GLP-1 prices to participating states in exchange for standardized coverage criteria, potentially reversing the exclusion trend.
• Medicaid GLP-1 spending reached nearly $9 billion in 2024, and utilization growth shows no sign of slowing — meaning coverage decisions will remain under fiscal pressure.

This is independent information and not medical advice, reimbursement guidance, or a recommendation for any specific state Medicaid program.

Sources

• KFF. "Medicaid Coverage of and Spending on GLP-1s." 2026. https://www.kff.org/medicaid/medicaid-coverage-of-and-spending-on-glp-1s
• KFF. "What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid and the Medicare GLP-1 Bridge." 2026. https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid
• NCSL. "GLP-1s: Cost, Coverage and State Policy Trends." 2026. https://www.ncsl.org/health/glp-1s-cost-coverage-state-policy-trends
• Pennsylvania DHS. "Medical Assistance Bulletin: Coverage Change and Prior Authorization of GLP-1 Receptor Agonists." November 24, 2025. https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/docs/publications/documents/forms-and-pubs-omap/mab2025112403.pdf
• Pennsylvania Health Law Project. "Pa. Medicaid Ends Adult Coverage of GLP-1s for Weight Loss." 2026. https://www.phlp.org/en/news/pa-medicaid-ends-adult-coverage-of-glp-1s-for-weight-loss
• Colorado General Assembly. "Navigating the GLP-1 Landscape: Evidence-Based Insights." 2026. https://content.leg.colorado.gov/sites/default/files/R25-1235_Navigating%20the%20GLP-1%20Landscape%20Evidence-Based%20Insights.pdf
• AAOPM. "Does Medicaid Cover Weight Loss Medication? A State-by-State Guide." 2026. https://aaopm.com/blog/does-medicaid-cover-weight-loss-medication
• The Guardian. "US states drop Medicaid coverage of GLP-1 weight-loss drugs as demand rises." April 14, 2026. https://www.theguardian.com/us-news/2026/apr/14/states-medicaid-coverage-glp-1
• Penn LDI. "Patients Face New Barriers for GLP-1 Drugs." 2026. https://ldi.upenn.edu/our-work/research-updates/patients-face-new-barriers-for-glp-1-drugs-like-wegovy-and-ozempic
• Healthcare Dive. "Few state Medicaid programs cover GLP-1s for obesity: KFF." 2026. https://www.healthcaredive.com/news/medicaid-state-coverage-glp1s-obesity-KFF/732044
• Delaware DHR. "State Coverage of GLP-1s for Weight Loss." 2025. https://dhr.delaware.gov/benefits/sebc/documents/2025/1216-coverage-of-glp1-for-weight-loss.pdf
• CMS. "Medicaid Drug Rebate Program." https://www.cms.gov/medicaid/medicaid-drug-rebate-program
• HHS. "Trump Administration Announces GENEROUS Model for GLP-1 Drug Pricing." 2025. https://www.hhs.gov/about/news/2025/11/06/trump-administration-announces-generous-model.html