North Carolina Medicaid covers GLP-1 receptor agonists for type 2 diabetes without interruption but has oscillated sharply on coverage for weight management. In October 2025, NC Medicaid removed Wegovy, Zepbound, and Saxenda from the Preferred Drug List (PDL) for weight-loss indications, then reinstated them in December 2025 under a governor's directive. As of January 2026, Wegovy is a Preferred product and Zepbound and Saxenda are Non-Preferred products on the NC Medicaid PDL, with coverage managed through NCTracks prior authorization using clinical criteria effective August 1, 2024.
This guide maps which GLP-1 medications NC Medicaid covers under which diagnoses, details the prior authorization (PA) criteria for weight management and non-weight-management indications, explains the policy reversal timeline, and provides a drug-by-drug coverage summary. It is independent information and not medical advice or reimbursement guidance for a specific patient or plan.
Quick answer
| GLP-1 Drug | NC Medicaid Weight Management | NC Medicaid Type 2 Diabetes | NC Medicaid Cardio/MASH/OSA |
|---|---|---|---|
| Wegovy (semaglutide 2.4 mg injection) | Covered — Preferred, PA required | Not applicable (use Ozempic) | Covered — cardioprotection, MASH |
| Zepbound (tirzepatide injection) | Covered — Non-Preferred, PA required | Not applicable (use Mounjaro) | Covered — obstructive sleep apnea |
| Saxenda (liraglutide injection) | Covered — Non-Preferred, PA required | Not applicable (use Victoza) | Not covered for other indications |
| Ozempic (semaglutide injection) | Not applicable | Covered — PA required | Not applicable |
| Mounjaro (tirzepatide injection) | Not applicable | Covered — PA required | Not applicable |
| Trulicity (dulaglutide injection) | Not applicable | Covered — PA required | Not applicable |
Policy reversal timeline
NC Medicaid's GLP-1 weight-management coverage has changed three times in under a year:
- August 1, 2024 — NC Medicaid established outpatient pharmacy prior approval criteria for GLP-1s for weight management, covering Wegovy, Zepbound, and Saxenda with PA through NCTracks.
- October 1, 2025 — NC Medicaid removed Wegovy, Zepbound, and Saxenda from the PDL as an off-cycle change, citing a budget stalemate in the state legislature. Wegovy and Zepbound continued to be covered for FDA-approved indications other than weight management (cardioprotection, MASH, sleep apnea) through separate clinical criteria. Saxenda was no longer covered for any indication. Existing PAs for weight management expired September 30, 2025.
- November 4, 2025 — NC Medicaid issued a bulletin clarifying that Wegovy and Zepbound for non-weight-loss indications would be covered based on FDA-approved labeling, pending updated clinical criteria to be promulgated under NCGS § 108A-54.2(b)(2).
- December 12, 2025 — Under the governor's directive, NC Medicaid reinstated GLP-1 coverage for obesity treatment. Coverage reverted to the criteria in place as of September 30, 2025 — the August 2024 PA criteria.
- January 15, 2026 — Provider Communication Bulletin #172 confirmed that Wegovy, Zepbound, and Saxenda were added back to the PDL as an off-cycle update. Wegovy is Preferred; Zepbound and Saxenda are Non-Preferred.
Weight management PA criteria
NC Medicaid uses the Outpatient Pharmacy Prior Approval Criteria GLP-1s for Weight Management (effective August 1, 2024) for all weight-management PA requests. These criteria apply to NC Medicaid Direct and NC Medicaid Managed Care, including prepaid health plans such as Partners Health Management, Alliance Health, AmeriHealth Caritas NC, and others.
Initial PA requirements
For an initial weight management PA, the prescriber must document:
- Baseline BMI measured within the past 45 days of the submitted PA, documented on the PA form with both weight and date.
- BMI thresholds:
- Adults (18+): BMI ≥ 30 kg/m², or BMI ≥ 27 kg/m² with at least one weight-related comorbidity (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia).
- Adolescents (12–17): BMI ≥ 95th percentile for age and sex, or BMI ≥ 30 kg/m², or BMI ≥ 85th percentile with at least one weight-related comorbidity.
- Lifestyle modification — the beneficiary is currently on and will continue structured nutrition and physical activity.
- No combination use with another GLP-1 receptor agonist.
- No FDA-labeled contraindications to the requested agent.
- Product must be FDA-approved for the indication, age, and weight (if applicable), and must not exceed dosing limits per prescribing information.
- Preferred drug requirement — the preferred drug on the PDL (Wegovy) is required unless the patient meets non-preferred PDL PA criteria, including completion of an adequate titration period of 3 to 6 months of the preferred drug.
Duration of approval
- Initial approval: 6 months.
- Renewal approval: 12 months.
- No limit on the number of renewals.
Renewal PA requirements
At each renewal (reauthorization), the prescriber must document:
- Adults: The patient has lost a total of 5% of pretreatment weight and maintains the 5% weight loss. Baseline and current weight must be provided on the PA form.
- Adolescents (12–17): Greater than 4% reduction in baseline BMI, with weight loss maintained. Baseline and current weight required.
- Exception pathway: Adults or adolescents with a documented weight loss deemed to be a significant reduction from BMI per the prescriber, even if the 5%/4% threshold is not met. Rationale, baseline, and current weight must be provided.
- Medication review: The provider must document that a review of the beneficiary's medication list has been performed for possible dose reductions or discontinuation of comorbidity medications that may no longer be needed due to weight reduction effects.
- Ongoing lifestyle modification must be confirmed.
Quantity limits
- Wegovy: 3 mL per 28 days (titration doses: 2 mL per 28 days).
- Saxenda: 15 mL per 30 days.
- Zepbound: 2 mL per 28 days.
Non-weight-management indications
NC Medicaid covers Wegovy and Zepbound for FDA-approved indications other than weight management under separate clinical criteria, also processed through NCTracks.
Wegovy for cardioprotection
- Documented baseline BMI prior to beginning therapy > 27 kg/m².
- Beneficiary is 45 years of age or older.
- Established cardiovascular disease (history of myocardial infarction, stroke, or symptomatic peripheral arterial disease).
- At least 3 months of lifestyle modifications prior to starting Wegovy.
- No personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.
- Duration of approval: 6 months for initial and renewals.
Wegovy for MASH (noncirrhotic)
- Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis (stages F2–F3).
- FIB-4 score consistent with stage F1, F2, or F3 fibrosis adjusted for age.
- Confirmation via liver biopsy, vibration-controlled transient elastography (VCTE/FibroScan), enhanced liver fibrosis (ELF) score, magnetic resonance elastography (MRE), or FibroSure.
- Adult (18+).
- Baseline BMI > 25 kg/m² (> 23 kg/m² for South Asian, Southeast Asian, or East Asian descent).
Zepbound for obstructive sleep apnea
- Beneficiary is 18 years or older.
- Diagnosis of moderate to severe obstructive sleep apnea with obesity.
- Documented baseline BMI > 40 kg/m² prior to beginning therapy.
- Zepbound prescribed per FDA-approved indications, age, and dosing limits.
Continuation requests
For all non-weight-management indications, continuation requests require:
- Confirmation that the beneficiary was previously approved through NC Medicaid's PA process for the covered indication.
- Medical documentation that the beneficiary has improved while on the medication.
- Individual clinical goals set by the provider are being met.
- Beneficiary is continuing to make adequate progress toward treatment goals.
How to submit PA requests
NC Medicaid processes GLP-1 PA requests through NCTracks:
- Phone: NCTracks Call Center at 800-688-6696.
- Fax: NCTracks secure PA fax line.
- Portal: NCTracks secure prior authorization portal — identified by NC Medicaid as the most efficient method for PA processing.
- UnitedHealthcare Community Plan PA form: NC Medicaid Managed Care members enrolled in UHC Community Plan may use the specific NC GLP-1 Wegovy and Zepbound PA form available at uhcprovider.com.
For members enrolled in NC Medicaid Managed Care prepaid health plans (Partners Health Management, Alliance Health, AmeriHealth Caritas NC, Carolina Complete Health, Healthy Blue, UnitedHealthcare Community Plan, WellCare), PA requests should follow the specific plan's process, though clinical criteria are state-standardized per the NCTracks criteria.
Important notes for prescribers
- Lapse in therapy: After the October–December 2025 coverage gap, prescribers should assess whether members experienced a lapse in treatment, a change in therapy, or require a lower starting dose upon reinitiation. NC Medicaid advises reviewing applicable safety considerations and educating patients as appropriate.
- Diagnosis codes: For GLP-1 medications covered for diabetes (Ozempic, Mounjaro, Trulicity, Victoza), the prescriber must submit a diagnosis code with the prescription. No changes have been made to diabetes GLP-1 coverage.
- EPSDT for members under 21: For NC Medicaid members younger than 21 who need GLP-1 drugs for weight loss, coverage continues to be available under federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requirements, with PA submission.
- 3.1 million North Carolinians have health care coverage through Medicaid as of 2025, according to NC Medicaid.
NC Medicaid enrollment context
NC Medicaid operates both a Direct (fee-for-service) program and a Managed Care program with six prepaid health plans. More than 3.1 million North Carolinians are enrolled. GLP-1 PA criteria apply uniformly across both Direct and Managed Care, though Managed Care plans may have additional formulary management or pharmacy network requirements.
According to KFF's January 2026 analysis, North Carolina is one of 13 state Medicaid programs that covered GLP-1s for obesity treatment under fee-for-service as of January 2026 — down from 16 states in October 2025, after California, New Hampshire, Pennsylvania, and South Carolina eliminated coverage.
Sources
- NC Medicaid, "NC Medicaid to Change Coverage for GLP-1 Weight Management Medications," September 5, 2025. https://medicaid.ncdhhs.gov/blog/2025/09/05/nc-medicaid-change-coverage-glp-1-weight-management-medications
- NC Medicaid, "NC Medicaid to Reinstitute Coverage of GLP-1s for Weight Management," December 19, 2025. https://medicaid.ncdhhs.gov/blog/2025/12/19/nc-medicaid-reinstitute-coverage-glp-1s-weight-management
- NC Medicaid, "Updates to NC Medicaid Coverage for Wegovy and Zepbound for Clinical Indications Other than Weight Loss," November 4, 2025. https://medicaid.ncdhhs.gov/blog/2025/11/04/updates-nc-medicaid-coverage-wegovy-and-zepbound-clinical-indications-other-weight-loss
- NC Medicaid Outpatient Pharmacy Prior Approval Criteria GLP1s for Weight Management, effective August 1, 2024. https://www.nctracks.nc.gov/content/dam/jcr:0e327f54-101e-41be-a89d-e13212b687b0/Weight%20Management-08.01.2024.pdf
- NC Medicaid Outpatient Pharmacy Prior Approval Criteria GLP1s for Weight Management — Wegovy and Zepbound (updated criteria). https://medicaid.ncdhhs.gov/media/15676/download?attachment=
- Partners Health Management, Provider Communication Bulletin #172, January 15, 2026. https://providers.partnersbhm.org/provider-communication-bulletin-172
- UnitedHealthcare, NC GLP-1 Wegovy and Zepbound PA Form. https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/uhccp-pharmacy-forms/d-g/NC-GLP1-Wegovy-Zepbound-PA-Form.pdf
- NC Medicaid Preferred Drug List, effective January 1, 2026. https://medicaid.ncdhhs.gov/nc-medicaid-preferred-drug-list-effective-january-1-2026-revised-121025/open
- KFF, "Medicaid Coverage of and Spending on GLP-1s," January 2026. https://www.kff.org/medicaid/medicaid-coverage-of-and-spending-on-glp-1s
- CMS, "Medicare GLP-1 Bridge: Information for Medicare Beneficiaries." https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge/information-medicare-beneficiaries
