in 84 days LillyDirect self-pay — Foundayo™ (orforglipron) 2.5 mg moves to $199/month See the changelog
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Medicaid (state-by-state)

State programs + BALANCE model · updated September 28, 2026

Coverage right now

Coverage of GLP-1s for obesity is state-by-state and shrinking: 13 states as of Jan 2026 (KFF count), 11 at the RX Index tracker's July 10, 2026 snapshot after Utah's pilot ended June 30 and MassHealth ended coverage July 3. Every count here is dated to the snapshot that produced it — neither source publishes a current national total, and the tracker says so explicitly. Rhode Island stops covering GLP-1s prescribed solely for weight loss on Oct 1, 2026 under its enacted FY2027 budget, taking the count to 10 — other medically accepted indications stay reachable there by prior authorization. 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; its negotiated drug list is all formulations of Mounjaro, Ozempic, Rybelsus and Wegovy, the KwikPen formulation of Zepbound, and Foundayo, for their diabetes indications as well as weight management. CMS says Medicaid coverage under the model depends on both manufacturer and state participation and guarantees coverage to no individual. The participating-state list was still unpublished as of Sep 8, 2026 (applications closed July 31).

Drug status

DrugStatusDetailConfidence
Zepbound® (tirzepatide)Varies Covered for obesity in ~13 states (some restricted) — KFF's count, current as of Jan 2026. Of the Zepbound formulations, BALANCE includes the KwikPen only. sourcemedium
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 — the tracker's July 10, 2026 snapshot, which it does not carry forward as a current total. Rhode Island stops covering GLP-1s prescribed solely for weight loss on Oct 1, 2026. Of the Zepbound formulations, BALANCE includes the KwikPen only. sourcemedium
Zepbound® (tirzepatide)Varies
from Oct 1, 2026
~10 states, being the tracker's July 10, 2026 snapshot of 11 less Rhode Island — our arithmetic on a snapshot the tracker does not carry forward, not a count it publishes for this date. Rhode Island still reviews Zepbound for obstructive sleep apnea on a new prior authorization, and every Rhode Island request for a member under 21 is reviewed for medical necessity under EPSDT. Of the Zepbound formulations, BALANCE includes the KwikPen only. therxindex.com· eohhs.ri.gov· eohhs.ri.govmedium
Wegovy® (semaglutide injection)Varies Covered for obesity in ~13 states — KFF's count, current as of Jan 2026. MASH/CV indications open separate doors in non-covering states. sourcemedium
Wegovy® (semaglutide injection)Varies
from Jul 1, 2026 to Sep 30, 2026
Covered for obesity in ~11 states after Utah and Massachusetts ended coverage — the tracker's July 10, 2026 snapshot, which it does not carry forward as a current total; Rhode Island stops covering GLP-1s prescribed solely for weight loss on Oct 1, 2026. MASH/CV indications open separate doors in non-covering states. sourcemedium
Wegovy® (semaglutide injection)Varies
from Oct 1, 2026
~10 states, being the tracker's July 10, 2026 snapshot of 11 less Rhode Island — our arithmetic on a snapshot the tracker does not carry forward, not a count it publishes for this date. Rhode Island still reviews Wegovy for MASH or cardiovascular disease on a new prior authorization, and every Rhode Island request for a member under 21 is reviewed for medical necessity under EPSDT. MASH/CV indications open separate doors in non-covering states. therxindex.com· eohhs.ri.gov· eohhs.ri.govmedium

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 California kept two doors open after dropping weight-loss GLP-1s from the Medi-Cal Rx contract list: members under 21 can still have a weight-loss request reviewed for medical necessity under the federal EPSDT benefit, and Wegovy for MASH or cardiovascular disease and Zepbound for obstructive sleep apnea remain reviewable by prior authorization for everyone. Otherwise Wegovy, Zepbound and Saxenda deny with Reject Code 70 and existing approvals expired 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
  • Jan 1, 2026 Michigan Medicaid reduced obesity GLP-1 coverage under Public Act 22 of 2025 (FY2026 budget) rather than eliminating it: liraglutide, Saxenda, Wegovy and Zepbound keep their other covered indications unchanged, while a request to treat obesity now needs the patient classified as morbidly obese, documented failure of all other clinically appropriate weight-loss interventions including the preferred anti-obesity agents, and a prescriber attestation that the drug is considered only as a measure to avert the need for higher-cost bariatric surgery. Authorizations approved before Jan 1, 2026 were honored for their remaining six months, and Saxenda and Wegovy became non-preferred on the Single PDL for their other indications, which carries a $3 copayment instead of $1 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 Medicaid stops covering Foundayo, Saxenda, Wegovy and Zepbound when prescribed solely for weight loss, under its enacted FY2027 budget; obesity coverage runs through Sept 30, 2026. Continued treatment for an indication other than weight loss needs a new prior authorization, and requests for members under 21 are reviewed for medical necessity under EPSDT 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. Rhode Island's Oct 1 change now rests on two EOHHS documents of its own rather than on the tracker and press coverage: the September 2026 Provider Update (PU 404), and a dedicated memo to providers dated Aug 5, 2026 and titled 'GLP-1 State Budget Guidance' (read 2026-09-28), which names the same four drugs, the same 'solely for weight loss' limit, the same new-PA route for other indications and the same EPSDT review for members under 21, and the state's wording is narrower than theirs: RI Medicaid stops covering Foundayo, Saxenda, Wegovy and Zepbound 'when they are prescribed solely for weight loss', NOT 'only for type 2 diabetes' as the tracker, the ADA release and the legislative testimony all put it. The difference is the whole answer for a Rhode Island reader with a non-weight-loss indication — Zepbound for obstructive sleep apnea, Wegovy for MASH or cardiovascular disease — who keeps a pathway by submitting a NEW prior authorization with clinical documentation, and for anyone under 21, whose request is reviewed for medical necessity under EPSDT regardless of indication. The notice says the four-drug list 'includes' those products, so treat it as the named set rather than a closed one. The tracker RETRACTED its count as a current figure in its 2026-09-25 release (read 2026-09-28): it now labels the 11 a 'July 10, 2026 historical snapshot', says in terms that it is a 'Historical count, not a current national total', that 'the older count is not a newly verified September total', and — the part that bites hardest on a state-by-state claim — that 'absence from the historical roster is not a current non-coverage finding'. It also warns that 'the page-update date does not mean every state's policy was reverified that day'; each state row now carries its own review date, and many read 'Not reverified'. So the 11 and the 10 derived from it are dated snapshots, not present-tense coverage counts, and the rows above now say so. Nothing about the number changed — what changed is that the source withdrew it as current, which is a change to the evidence and not to the fact. The rows above stay medium because their headline claim is the ~10-state COUNT, which is still the tracker's; the Rhode Island sentences in them are high-confidence and carry the state's own citation alongside. Foundayo and Saxenda are named by Rhode Island but have no status row in this file, which tracks only zepbound and wegovy nationally — a gap worth closing if a second state names them. Michigan is the one state on that list whose parenthesised restricted note is now backed from the state's own documents, and the restriction is stricter than the press coverage of it: MDHHS letter L-25-73 says only that the patient must be classified as morbidly obese and publishes no number, while the MHP Common Formulary Prior Authorization Criteria effective Sept 1 2026 puts the adult threshold at a baseline BMI of 40 kg/m2 or greater and requires trial and failure of ALL FIVE preferred non-GLP-1 classes — benzphetamine, diethylpropion, orlistat, phendimetrazine and phentermine products, the last of which includes generic phentermine/topiramate — where the Michigan press reported only phentermine and Qsymia. The same criteria make every anti-obesity GLP-1 non-preferred (liraglutide, Saxenda, Wegovy pens and tablets, Wegovy HD, Zepbound), set the age floor at 18 for Wegovy HD, Wegovy tablets and Zepbound against 12 for Wegovy injectable and Saxenda, bar concurrent DPP-4 inhibitors, and renew only on a maintained weight loss of 5% or more. Foundayo is absent from that 284-page document entirely, so Michigan publishes no anti-obesity pathway for the oral at all. Michigan still has no plan file of its own: its appeal route is not recorded, and the bar for a new payer file is status AND criteria AND appeal.
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.