Medicaid Protection of and Spending on GLP-1s

GLP-1 (glucagon-like peptide-1) medication had been initially developed to assist folks with sort 2 diabetes handle blood sugar ranges however have gained widespread attention for his or her effectiveness as a remedy for weight problems. As a result of their price, nevertheless, protection of GLP-1s for weight problems remedy in Medicaid, ACA Marketplace plans, and most giant employer corporations stays restricted, and GLP-1 protection in Medicare for remedy of weight problems is prohibited underneath present legislation. Whereas state Medicaid applications should cowl almost all Meals and Drug Administration (FDA) authorised medication, a long-standing statutory exception permits states to select whether or not to cowl weight-loss medication underneath Medicaid. Consequently, Medicaid protection of GLP-1 medication for weight problems remedy is elective for states, whereas protection for different indications (diabetes, heart problems, and sleep apnea) is required.

The upfront prices of GLP-1s are an ongoing concern for each public and private payers, and a few employers and state Medicaid applications at the moment are limiting protection, regardless of recognizing their effectiveness at treating weight problems. Expanded weight problems drug protection can improve Medicaid spending and put pressure on general state budgets, and states at the moment are going through tighter finances circumstances and longer-term fiscal uncertainty, due partially to the federal Medicaid cuts within the 2025 reconciliation legislation, inflicting state Medicaid applications to re-evaluate their weight problems drug protection. Nonetheless, almost four in ten adults and a quarter of youngsters with Medicaid have weight problems, that means increasing Medicaid protection of those medication may present entry to efficient weight problems therapies for thousands and thousands. In the long run, decreased weight problems charges amongst Medicaid enrollees may additionally end in decreased Medicaid spending on chronic diseases related to weight problems, although the proof is mixed. Any financial savings on Health spending due to weight problems medication might take a few years and should not accrue to the Medicaid program if people expertise shifts in protection, so states is probably not factoring long-term financial savings into protection choices.

On the federal stage, the Trump administration determined to not proceed with a Biden administration proposal to permit Medicare and require Medicaid to cowl weight problems medication however just lately launched their very own weight problems drug protection initiatives to scale back prices and improve entry (see Field 1). Whereas decrease costs for state Medicaid applications may assist alleviate price issues for states and end in expanded protection of weight problems medication, how the brand new decrease prices examine to the web costs state Medicaid applications at present pay and the way states will respond amid tightening finances circumstances stay unclear. Additional, the current bulletins is not going to affect prices for Medicaid enrollees as they already pay little or no copays for pharmaceuticals, and the prices of buying medication straight from producers by way of TrumpRx will possible nonetheless be prohibitive for folks on Medicaid who will need to have a low earnings to qualify for this system. Except Medicaid covers weight problems medicines, enrollees are unlikely to have entry to them given the excessive out-of-pocket price even at decrease costs. 

This temporary discusses the present panorama of Medicaid GLP-1 protection and examines current tendencies in Medicaid prescriptions and gross spending on GLP-1s. Key takeaways embrace:

• Weight problems drug protection in Medicaid stays restricted, with 13 state Medicaid applications masking GLP-1s for weight problems remedy underneath fee-for-service (FFS) as of January 2026.
• The variety of Medicaid prescriptions and gross spending on GLP-1s have each elevated considerably since 2019.
• Elevated utilization of Ozempic and Wegovy (semaglutide) in addition to Mounjaro and Zepbound (tirzepatide) have contributed considerably to current development.

Does Medicaid cowl GLP-1s for weight problems remedy?

States can determine whether or not to cowl weight problems medication underneath Medicaid. Below the Medicaid Drug Rebate Program, Medicaid applications should cowl almost all of a collaborating producer’s FDA-approved medication for medically accepted indications. Nonetheless, weight-loss medication are included in a small group of medication that can be excluded from protection¹ (although the statutory exception refers to brokers used for “weight reduction”, “weight problems medication” is used to consult with this group of medicines on this evaluation). Consequently, protection of GLP-1 medication for the remedy of weight problems stays elective for states, whereas protection is required for medication authorised for the remedy of diabetes and, since March 2024 and December 2024, for the remedy of heart problems (Wegovy) and reasonable to extreme obstructive sleep apnea in adults with weight problems (Zepbound), respectively (Desk 1). Protection can be required if deemed medically crucial for kids underneath Medicaid’s Early and Periodic Screening, Diagnostic and Remedy (EPSDT) profit.

Weight problems drug protection in Medicaid stays restricted, with 13 state Medicaid applications masking GLP-1s for weight problems remedy underneath FFS as of January 2026 (Determine 1). When coated, GLP-1s are usually topic to utilization controls akin to prior authorization, which might additional restrict entry. Notably, KFF’s 2025 Medicaid finances survey discovered 16 state Medicaid applications coated GLP-1s for weight problems remedy as of October 2025; nevertheless, since then, 4 states (California, New Hampshire, Pennsylvania, and South Carolina) have eradicated protection of GLP-1s for weight problems remedy, possible reflecting current state finances challenges and the numerous prices related to protection. North Carolina eradicated GLP-1 protection starting October 2025 on account of a finances stalemate within the legislature, however protection was reinstated in December 2025, bringing the entire variety of states masking GLP-1s for weight problems to 13 as of January 2026. Just a few different states are planning or contemplating weight problems drug restrictions in state fiscal 12 months 2026 or 2027, and state curiosity in increasing protection of weight problems medication can be waning in accordance with this 12 months’s survey, with states persevering with to report price as the important thing issue contributing to weight problems drug protection choices. The state weight problems drug protection panorama will proceed to evolve as states reply to the current announcement of the BALANCE mannequin (see Field 1) and as states deal with finances challenges and the federal Medicaid spending cuts within the 2025 reconciliation legislation.

How have Medicaid prescriptions and gross spending on GLP-1s modified lately?

The variety of Medicaid prescriptions and gross spending on GLP-1s have elevated considerably since 2019 (Determine 2). Not all GLP-1s are authorised for weight problems remedy, and this evaluation consists of all FDA-approved GLP-1s, together with these authorised for weight problems (Saxenda, Weogvy, Zepbound) in addition to these authorised for sort 2 diabetes (see Desk 1). General, the variety of GLP-1 prescriptions elevated sevenfold, from about 1 million in 2019 to over 8 million in 2024. On the identical time, gross spending elevated ninefold, from about $1 billion in 2019 to virtually $9 billion in 2024, and gross spending per GLP-1 prescription reached $1,000 in 2024. Preliminary tendencies by way of June 2025 (knowledge not proven) present fast development will proceed in 2025. These costs and spending numbers don’t account for rebates, and states usually obtain substantial rebates on brand medication. In response to rising criticism of the price of their medication, Novo Nordisk, the corporate that manufactures Ozempic and Wegovy, Health-law-and-business/ozempics-price-is-becoming-tougher-for-novo-nordisk-to-justify”>reported final 12 months that deductions and different charges (throughout all payers) accounted for about 40% of the price of the 2 medication and that they anticipated rebates to develop. GLP-1s nonetheless account for a comparatively small share of the entire variety of Medicaid prescriptions, accounting for about 1% of all Medicaid prescriptions in 2024 (up from about 0% in 2019). Nonetheless, GLP-1s accounted for over 8% of all Medicaid prescription drug spending earlier than rebates in 2024 (up from 1% in 2019).

Particularly, elevated utilization of Ozempic and Wegovy (semaglutide) in addition to Mounjaro and Zepbound (tirzepatide) have contributed considerably to current development. Prescriptions and spending on Ozempic, authorised for sort 2 diabetes (not weight problems) in 2017, have grown significantly over the interval. By 2024, Ozempic had surpassed Trulicity, additionally authorised for sort 2 diabetes (not weight problems) to make up the biggest share of GLP-1 prescriptions and spending (39% in 2024). Trying from 2023 to 2024, the newest 12 months of knowledge out there, prescriptions and gross spending for Wegovy (first authorised for weight problems in 2021, authorised for heart problems in 2024) and Mounjaro (authorised for sort 2 diabetes in 2022) greater than doubled, and prescriptions and gross spending for Zepbound (first authorised for weight problems in 2023, authorised for sleep apnea in 2024) elevated greater than fivefold. These medication are produced by Novo Nordisk and Eli Lilly, which each just lately introduced agreements with the Trump administration to decrease costs. From Medicaid knowledge publicly out there, there is no such thing as a means but to disentangle how a lot of the rising use of GLP-1s is said to remedy for diabetes, heart problems, or sleep apnea versus weight problems, or a mix.