Medicaid (state-by-state)
State programs + BALANCE model · updated August 8, 2026
Coverage right now
- Wegovy® (semaglutide injection) Varies
- Zepbound® (tirzepatide) Varies
Coverage of GLP-1s for obesity is state-by-state: 13 states as of Jan 2026 (KFF count). Four states 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lets states buy in at negotiated prices with rolling starts May 2026 - Jan 2027; the participating-state list was still unpublished as of Aug 8, 2026 (applications closed July 31).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 |
| Wegovy® (semaglutide injection) | Varies | Covered for obesity in ~13 states; MASH/CV indications open separate doors in non-covering states. source | medium |
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
- May 1, 2026 BALANCE Medicaid rolling participation window opened source
- Jul 31, 2026 BALANCE state application deadline passed; participant list not yet published source
Best-available named list of covering states (tracker, Apr 2026, medium confidence): DE, KS (restricted), MA (restricted), MI (restricted), MN, MS, MO, NC, RI, TN, UT, VA, WI. KFF confirms the COUNT (13) but not the list. 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.