Medicaid
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (HTN, T2DM, OSA, CVD, and dyslipidemia)
- BMI at or above the 95th percentile for age and sex
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult (18+) — BMI ≥ 30
All of:
- Age 18 or older
- BMI ≥ 30 kg/m²
- FDA approved for indication, age, weight, and does not exceed dosing limits
- Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
- Baseline weight and BMI documented within past 45 days on PA form
- Beneficiary is new to therapy or attempting a repeat weight loss course
- Currently on and will continue lifestyle modification (structured nutrition and physical activity)
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Adult (18+) — BMI ≥ 27 with comorbidity
All of:
- Age 18 or older
- BMI ≥ 27 kg/m²
- At least one weight-related comorbidity/risk factor/complication (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
- FDA approved for indication, age, weight, and does not exceed dosing limits
- Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
- Baseline weight and BMI documented within past 45 days on PA form
- Beneficiary is new to therapy or attempting a repeat weight loss course
- Currently on and will continue lifestyle modification (structured nutrition and physical activity)
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Adolescent (12–17) — BMI ≥ 95th percentile or ≥ 30
All of:
- Age 12–17 years
- FDA approved for indication, age, weight, and does not exceed dosing limits
- Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
- Baseline weight and BMI documented within past 45 days on PA form
- Beneficiary is new to therapy or attempting a repeat weight loss course
- Currently on and will continue lifestyle modification (structured nutrition and physical activity)
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Plus any one of:
- BMI ≥ 95th percentile for age and sex
- BMI ≥ 30 kg/m²
Adolescent (12–17) — BMI ≥ 85th percentile with severe comorbidity
All of:
- Age 12–17 years
- BMI ≥ 85th percentile for age and sex
- At least one severe weight-related comorbidity/risk factor/complication
- FDA approved for indication, age, weight, and does not exceed dosing limits
- Preferred drug trial completed (3–6 months titration) unless contraindicated or patient meets non-preferred PDL PA criteria
- Baseline weight and BMI documented within past 45 days on PA form
- Beneficiary is new to therapy or attempting a repeat weight loss course
- Currently on and will continue lifestyle modification (structured nutrition and physical activity)
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Documentation to bring
- Baseline weight and BMI (measured within the past 45 days) documented on PA form
- Documentation of preferred drug trial (3–6 months titration) or documented contraindication to preferred drug
- Documentation that beneficiary is new to therapy or attempting a repeat weight loss course
- For adults with comorbidity pathway: documentation of qualifying weight-related comorbidity (HTN, T2DM, OSA, CVD, or dyslipidemia)
- For adolescent 85th percentile pathway: documentation of severe weight-related comorbidity
Quantity limits
- titration doses — 2 mL per 28 days
- maintenance doses — 3 mL per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: 5% total pretreatment weight loss maintained. Adolescents (12 to <18): >4% reduction in baseline BMI maintained. Alternatively, adults or adolescents with documented weight loss deemed significant per prescriber even if 5%/4% thresholds not met, with rationale. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. At each renewal, provider must document review of medication list for possible dose reductions or discontinuation of comorbid medications no longer needed due to weight reduction effects. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Lactation
- History of medullary thyroid carcinoma
- Multiple endocrine neoplasia syndrome type 2 (MEN2)
- Concurrent use with another GLP-1 receptor agonist
- Pregnancy
Policy note: Policy applies to NC Medicaid beneficiaries enrolled on date of service. EPSDT provisions apply for beneficiaries under 21 years of age. If the preferred PDL drug exists for this indication, a trial of 3–6 months of the preferred drug (including adequate titration) is required before approval of a non-preferred agent, unless contraindicated. Titration can take up to 6 months for GLP-1s. Adolescent renewal threshold is >4% reduction in baseline BMI (not weight). The 12-month renewal duration applies to weight_loss indication; renewal requires prior PA approval through Medicaid.
Policy effective August 1, 2024 · verified June 4, 2026 · source: download