State-by-State Divide Over GLP-1 Medicaid Coverage

State-by-State Divide Over GLP-1 Medicaid Coverage

by Simplefill

Glucagon-like peptide-1, known as GLP-1, is a hormone that the body naturally makes to regulate digestion, blood sugar, and appetite. For years, people with type 2 diabetes have relied on a synthetic version of the hormone, called a GLP-1 agonist, to help them manage their symptoms and maintain normal blood sugar levels.

Recently, however, more people are relying on these GLP-1 medications to address obesity. The drug can help people stay fuller for longer, leading to reduced caloric intake and potentially dramatic weight loss results.

One of the issues that people who rely on these medications face, however, is that Medicaid coverage is not uniform throughout the country. GLP-1 is covered in some states for both diabetes and obesity treatment, while there may be restrictions in other states. GLP-1 medications are expensive, and this could result in people not having access to the drugs they need.

Understanding Medicaid Coverage of GLP-1

States have the authority to decide whether to provide coverage for GLP-1 drugs under Medicaid. This often takes people by surprise because of the supposed coverage that the Medicaid Drug Rebate Program guarantees for the majority of FDA-approved drugs.

The problem is that weight-loss drugs belong to a small group of medications that can be excluded. There are three GLP-1 drugs that the FDA has approved for the treatment of obesity: Zepbound (tirzepatide), Saxenda (liraglutide), and Wegovy (semaglutide). Medicaid does not have to cover these, though some state programs do.

Some GLP-1 drug formulations are used to treat type 2 diabetes, and Medicaid must cover them nationwide. Additionally, these medications are covered for the treatment of childhood obesity under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

As of 2025, only 14 states provide coverage for GLP-1 medications meant for the treatment of obesity in adults. Although Congress has considered the idea of putting into place laws that would require national availability, the plans have stalled.

Why Are They So Expensive?

The main challenge in the debate over Medicaid coverage is the high price tag of GLP-1 medications. The cost to a patient can be over $1,000 per month without insurance. Some reasons for this high price are:

  • Research and Development: Pharmaceutical companies invest billions of dollars in researching, developing, and testing new drugs.
  • Manufacturing and Supply Chain: These are not straightforward pills to produce. The injectables, in particular, require complex manufacturing processes and specialized delivery devices.
  • Patent Protection: When a new drug is approved, the company that developed it is granted a patent. With this, they have the monopoly on the price for some time.
  • Market Demand and Competition: With the recent surge in demand for these drugs for both diabetes and obesity, companies can command higher prices.

Limits to Medicaid Expansion

The Trump administration doesn’t support proposed Medicaid expansions under the Affordable Care Act (ACA). Recently, the administration stated that it would not put into place a proposed rule that would require coverage of these medications under Medicaid.

Even the states that do offer GLP-1 coverage have significant restrictions that could make the drug inaccessible for many. Body mass index requirements apply in the majority of these states, and prior authorization is also necessary.

Common GLP-1 Agonists

Here is a list of some of the most common GLP-1 medications approved by the FDA:

For Type 2 Diabetes:

  • Adlyxin (lixisenatide)
  • Ozempic (semaglutide)
  • Rybelsus (semaglutide, oral tablet)
  • Trulicity (dulaglutide)
  • Victoza (liraglutide)
  • Combination medications like Soliqua Vial (lixisenatide and insulin glargine)

For Obesity:

  • Saxenda (liraglutide)
  • Wegovy (semaglutide)
  • Zepbound (tirzepatide)

Numerous other states are considering adding these medications because of the potential benefits of reducing obesity and the health complications it may prompt. The problem is that this would be significantly expensive for the states. Many also cite their wish to see legislative changes that could make coverage easier.

Without support from the Trump administration, however, nationwide legislation seems unlikely. This means that it will still be up to the states to decide on Medicaid availability for these drugs. You can read our blog on Medicare’s First-Ever Price Negotiation Program to find out more.

Future Outlook and Legislative Efforts

The state-by-state divide over GLP-1 coverage is an issue that will change over time. Some differences patients may see are:

  • Potential for Federal Action: Although past federal attempts to mandate Medicaid coverage have stalled, the current administration heavily focuses on the effects of obesity on public health crises.
  • State-Level Changes: Some states may consider pilot programs to study the long-term cost-effectiveness of covering these drugs. Others might negotiate directly with pharmaceutical companies for better pricing or even implement value-based purchasing agreements, where payments are tied to patient outcomes.
  • Advocacy and Public Pressure: Patient advocacy groups and professional medical organizations will continue to exert increasing pressure on state and federal lawmakers over time.
  • New Drug Formulations: The introduction of new medications or a lower-cost generic version in the future would significantly alter the outcome of this debate.

How Prescription Assistance Programs Can Help

Prescription assistance programs can help individuals afford their medications. These programs are essential for people who are underinsured or completely uninsured. Prescription assistance programs help people gain access to discounts and can provide copay assistance. In some instances, it’s possible to receive free medications.

Pharmaceutical companies and non-profit organizations offer these programs, as do certain government agencies and other third parties. Some of these programs are the result of collaborations between all of these entities.

Each prescription assistance program has its own eligibility requirements and an application process. With assistance from these programs, it’s easier for people to adhere to their treatments and avoid skipping doses.

Get Affordable Access to Prescription Medications

Simplefill is a full-service prescription assistance company that researches, qualifies, and maintains patients’ enrollment in all sources of assistance available to them.

Apply today by calling 877-386-0206. A caring Simplefill representative will contact you within 24 hours to discuss your application and, if qualified, enroll you in the program.

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