Medicaid (state-by-state)
State programs + BALANCE model · updated August 31, 2026
Coverage right now
- Wegovy® (semaglutide injection) Varies
- Zepbound® (tirzepatide) Varies
Coverage of GLP-1s for obesity is state-by-state and shrinking: 13 states as of Jan 2026 (KFF count), 11 as of July 2026 after Utah's pilot ended June 30 and MassHealth ended coverage July 3. Rhode Island narrows to type 2 diabetes only on Oct 1, 2026 under its enacted FY2027 budget, taking the count to 10. Four states had already ELIMINATED coverage Jan 1, 2026 (CA, NH, PA, SC). The CMS BALANCE model lets states buy in at negotiated prices with rolling starts May 2026 - Jan 2027; the participating-state list was still unpublished as of Aug 16, 2026 (applications closed July 31).
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Varies | Covered for obesity in ~13 states (some restricted). BALANCE model drugs include Zepbound KwikPen only. source | medium |
| Zepbound® (tirzepatide) | Varies from Jul 1, 2026 to Sep 30, 2026 | Covered for obesity in ~11 states (some restricted) after Utah and Massachusetts ended coverage. Rhode Island narrows to type 2 diabetes only on Oct 1, 2026. BALANCE model drugs include Zepbound KwikPen only. source | medium |
| Zepbound® (tirzepatide) | Varies from Oct 1, 2026 | Covered for obesity in ~10 states (some restricted) after Rhode Island restricted its coverage to type 2 diabetes. BALANCE model drugs include Zepbound KwikPen only. source | medium |
| Wegovy® (semaglutide injection) | Varies | Covered for obesity in ~13 states; MASH/CV indications open separate doors in non-covering states. source | medium |
| Wegovy® (semaglutide injection) | Varies from Jul 1, 2026 to Sep 30, 2026 | Covered for obesity in ~11 states after Utah and Massachusetts ended coverage; Rhode Island narrows to type 2 diabetes only on Oct 1, 2026. MASH/CV indications open separate doors in non-covering states. source | medium |
| Wegovy® (semaglutide injection) | Varies from Oct 1, 2026 | Covered for obesity in ~10 states after Rhode Island restricted its coverage to type 2 diabetes. MASH/CV indications open separate doors in non-covering states. source | medium |
What these rules come to in dollars — every dose, priced under this coverage:
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
medium- PA required
- Yes in effectively all covering states, with restrictions (BMI thresholds, step therapy, program participation).
- Initial BMI
- State-specific.
- Comorbidities
- State-specific.
- Lifestyle requirement
- State-specific; several states require documented program participation.
- Initial authorization
- State-specific.
- Reauthorization
- State-specific.
- Step therapy
- Common.
- Quantity limits
- Common.
Primary criteria document: therxindex.com
Exceptions and appeals
- Appeal deadline
- 60 days
- Deadline detail
- 60 days to appeal with the MCO; after the MCO decision, up to 120 days to request a state fair hearing (42 CFR 438.408). Benefits can continue if you appeal before the action takes effect.
- Exception route
- Managed care: appeal with the MCO first (required). Fee-for-service: state fair hearing.
- Turnaround
- MCO resolves <= 30 days standard / <= 72h expedited. Fair hearing: final action within 90 days; expedited 3 working days.
- Where
- Your MCO / state Medicaid agency, per the notice.
Source: macpac.gov
Dated changes
- Jan 1, 2026 California, New Hampshire, Pennsylvania, South Carolina eliminated obesity GLP-1 coverage; North Carolina dropped Oct 2025 then reinstated Dec 2025 source
- Jan 1, 2026 Pennsylvania Medical Assistance also dropped Saxenda (liraglutide) for EVERY indication, not only for obesity — a withdrawal none of the multi-state trackers carry. Its own bulletin confirms GLP-1s stay covered for all other medically accepted indications with prior authorization, adds a GLP-1 therapeutic class to the Statewide PDL, and keeps non-GLP-1 obesity agents such as phentermine covered, preferred ones without PA source
- May 1, 2026 BALANCE Medicaid rolling participation window opened source
- Jun 30, 2026 Utah's obesity GLP-1 pilot ended; Utah no longer covers GLP-1s for weight management source
- Jul 3, 2026 MassHealth stopped covering drugs for the treatment of obesity or overweight (Wegovy, Zepbound, Saxenda, Xenical, phentermine); approved weight-loss PAs expired July 2. Coverage continues for type 2 diabetes and other approved indications. Brings the covering-state count to 11 source
- Jul 31, 2026 BALANCE state application deadline passed; participant list not yet published source
- Oct 1, 2026 Rhode Island restricts Medicaid GLP-1 coverage to type 2 diabetes under its enacted FY2027 budget; obesity coverage runs through Sept 30, 2026 source
Best-available named list of covering states (tracker, verified July 10 2026, medium confidence): DE, KS (restricted), MI (restricted), MN, MS, MO, NC, RI (obesity through Sept 30, 2026 only), TN, VA, WI. Massachusetts and Utah dropped off in mid-2026. MassHealth's own Pharmacy Facts #271 dates its end of obesity coverage to July 3 2026 (PAs expired July 2), not the July 1 that the tracker and the Boston press report; the status rows below still open on July 1 because Utah had already ended June 30 and a two-day gap would leave those dates with no row at all — the count is 12 on July 1-2 and 11 from July 3. KFF still reports the earlier COUNT (13, as of Jan 2026) and not the list; re-read 2026-08-30 and it has not been updated for the mid-2026 changes, so it is cited only for the pre-July rows. The tracker publishes TWO similarly-named pages and only one is current: glp1-medicaid-coverage-by-state (verified July 10 2026, count 11) is the live one, while medicaid-glp-1-coverage-by-state (verified April 10 2026, count 13) still shows Utah and Rhode Island as covering and does NOT support any mid-2026 row. Cite the first. Do not conflate this list with BALANCE participation — different programs.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.