New Hampshire Medicaid and GLP-1 coverage

The state announced the cut in writing and dated it. "Effective January 1, 2026, New Hampshire Medicaid will no longer cover GLP-1 medications when prescribed solely for weight loss. These medications will continue to be covered when prescribed for other chronic health conditions." The notice names the drugs — "GLP-1 medications (such as Saxenda, Wegovy, and Zepbound and any generic versions) will no longer be reimbursed by Medicaid if prescribed exclusively for weight loss purposes" — and names what survives: "the treatment of type 2 diabetes, major adverse cardiovascular events (MACE), severe obstructive sleep apnea and Metabolic Dysfunction-Associated Steatohepatitis (MASH)." It closes by directing providers to their managed care plan: "If there are questions on how one of the NH Medicaid Managed Care Organizations (MCO) handles the above information, please reach out to your MCO provider representative."

New Hampshire Department of Health and Human Services, Division of Medicaid Services, provider notice — Change in Medicaid Coverage for GLP-1 Medications, effective October 2025 · source

The drug list treats GLP-1s purely as diabetes drugs. Its class "ENDOCRINOLOGY – GLUCAGON-LIKE PEPTIDE-1 (GLP-1) AGONISTS AND ..." lists Ozempic, Trulicity and Victoza as preferred and exenatide, liraglutide, Mounjaro, Rybelsus and Soliqua as non-preferred. Wegovy, Zepbound and Saxenda appear nowhere in the 149,267-character document, under this or any other heading, and neither does the word obesity — the class-by-class list runs from analgesics to topical steroids with no anti-obesity class in it.

New Hampshire Department of Health and Human Services, Fee-for-Service Medicaid Preferred Drug List, effective July 2026 · source

The weight-management criteria open by ruling the whole drug class out. The first numbered condition for approval reads: "Medication requested is not a GLP-1 receptor agonist." What remains covered under that document is phentermine, Lomaira, phentermine/topiramate and orlistat, on a test of "Documented failure of at least a three-month trial on a low-calorie diet (1,200 kcal/day for women, 1,600 kcal/day for men)" plus a baseline BMI of "30 kg/m2 or more with no risk factors" or "27 kg/m2 or more with at least one very high-risk factor." The document then routes the GLP-1s away by name: "Requests for Wegovy for Major Adverse Cardiovascular Events, see separate Major Adverse Cardiovascular Events (Wegovy) criteria. Requests for Zepbound for Obstructive Sleep Apnea, see separate Obstructive Sleep Apnea (Zepbound) criteria."

New Hampshire Medicaid Fee-for-Service Program, Weight Management Criteria, effective October 2025 · source

Wegovy's heart-risk pathway asks that you already be on the standard prevention drugs. Alongside a documented three-month low-calorie diet trial, an activity regimen "including strength training to prevent lean muscle loss," a baseline BMI "at least 27 kg/m2 or more" and established cardiovascular disease, the criteria require that "The patient is currently taking guideline-recommended measures for the secondary prevention of a major adverse cardiovascular event (MACE)" — listing a statin at the maximally tolerated dose or ezetimibe or a PCSK9 inhibitor for dyslipidemia, blood-pressure optimization for hypertension, "A beta blocker for patients with a history of MI," and "An anticoagulant or antiplatelet therapy for patients with coronary artery disease (CAD) or other high-risk diagnoses." The last condition is that "The patient does not have a diagnosis of Type 1 or Type 2 Diabetes Mellitus." Initial approval is for six months.

New Hampshire Medicaid Fee-for-Service Program, Major Adverse Cardiovascular Events (MACE) – Wegovy Criteria, effective October 2025 · source

Zepbound's sleep-apnea pathway sets a CPAP adherence percentage, not just a trial. Beyond the same three-month diet trial, activity regimen and a baseline BMI "at least 27 kg/m2 or more," the state requires "a diagnosis of moderate-to severe obstructive sleep apnea (OSA) confirmed by an apnea-hypopnea index (AHI) of 15 or higher as determined by an in-lab attended sleep study or polysomnography (PSG)" and that "The patient has been adherent to positive airway pressure (PAP) for at least 70% in the last 6 months and will continue on PAP in combination with tirzepatide, unless intolerant or other rationale is provided." The patient must not have type 1 or type 2 diabetes. Initial approval is six months; renewal is twelve.

New Hampshire Medicaid Fee-for-Service Program, Obstructive Sleep Apnea (OSA) – Zepbound Criteria, effective October 2025 · source

The liver pathway is the most documentation-heavy of the three. New Hampshire covers Wegovy "in conjunction with reduced calorie diet and increase physical activity for the treatment of MASH, formerly NASH, with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults," and requires that the drug be "Prescribed by or in consultation with a gastroenterologist or hepatologist" and that fibrosis be established by liver biopsy within two years, elastography at "8.5 kilopascals (kPA) or more," magnetic resonance elastography, or a fibrosis blood test — plus an MRI-PDFF showing "8% or more liver fat." Rezdiffra is covered under the same document.

New Hampshire Medicaid Fee-for-Service Program, MASH (metabolic dysfunction-associated steatohepatitis) Criteria, effective October 2025 · source

The diabetes class is a separate document and a much shorter test. It covers Trulicity, Byetta, Victoza, Xultophy, Soliqua, Ozempic, Rybelsus and Mounjaro on four conditions: "Patient has a diagnosis of a type 2 diabetes mellitus; AND Patient age is supported by FDA-approved indication; AND Medication requested will be used as an adjunct to diet and exercise; AND Patient has had a trial of an oral antihyperglycemic." Length of approval is one year. This document was last revised by the state's DUR Board on 4/21/2026 and approved by the Commissioner Designee on 5/12/2026 — later than any of the obesity-adjacent criteria above.

New Hampshire Medicaid Fee-for-Service Program, GLP-1 Receptor Agonist Criteria, effective May 2026 · source

The department's own hearing rule gives 30 days and counts from the notice. He-C 201.03 states: "Unless otherwise specifically provided in applicable federal or state law, or other department administrative rules which set a different time limit, appeals shall be submitted within 30 days after the date: (1) The department's notice of decision was issued, if applicable; or (2) Of the department's notice to the appellant of its action if a notice of decision was not issued." The rule adds that "The time limits for filing appeals shall not be waived unless the appellant establishes good cause for the non-compliance," and elsewhere that "all time periods referenced in this chapter shall be calendar days" and that counting "shall begin with the day after the action which sets the time period in effect."

New Hampshire Code of Administrative Rules, He-C 200 (Rules of Practice and Procedure), He-C 201.03 · source

Managed care members face a different sequence with two longer clocks. WellSense Health Plan's New Hampshire Medicaid handbook states that "You must file your standard appeal with WellSense Health Plan over the phone or in writing within 60 calendar days of the date of the plan's written notice to you," that "Before you file a State Fair Hearing appeal with NH DHHS AAU, you must exhaust the first level of appeal through WellSense Health Plan," and that "You must request a standard State Fair Hearing in writing within 120 calendar days of the date on the plan's written decision." This is a plan document, not a state rule.

WellSense Health Plan, New Hampshire Medicaid Care Management Program Member Handbook (a plan document), effective September 2026 · source