North Carolina Medicaid and GLP-1 coverage

North Carolina ended this coverage first. Its September 2025 bulletin says: "Given shortfalls in state funding, effective Oct. 1, 2025, NC Medicaid coverage for GLP-1s for the treatment of obesity, which is an optional benefit for Medicaid programs, will be discontinued." It also says what stayed — coverage continued for diabetes, for reducing cardiovascular death, heart attack and stroke, for noncirrhotic MASH and for severe obstructive sleep apnea — and that Wegovy, Zepbound and Saxenda came off the preferred drug list as an off-cycle change, with Saxenda dropped for every indication.

NC Medicaid, Division of Health Benefits, NC Department of Health and Human Services, effective October 2025 · source

Ten weeks later it reversed. The December 2025 bulletin says that "Effective Dec. 12, 2025, coverage for GLP-1s for the treatment of obesity will be reverted to the coverage available as of Sept. 30, 2025," and that this happened "In accordance with the Governor's directive." Wegovy, Zepbound and Saxenda went back on the preferred drug list as an off-cycle change, with Wegovy preferred and the other two non-preferred, and the criteria reverted to the ones effective August 1, 2024. The bulletin also tells prescribers to consider whether a member has had a lapse in treatment and whether a lower starting dose is needed.

NC Medicaid, Division of Health Benefits, NC Department of Health and Human Services, effective December 2025 · source

The current state drug list still carries them. Under "WEIGHT MANAGEMENT AGENTS" it lists a class headed "GLP-1 Receptor Agonists indicated for the treatment of obesity (Incretin Mimemetics)" — the misspelling is the state's — with Wegovy pen and tablet preferred, and Saxenda, generic liraglutide and Zepbound non-preferred. The class carries the note that clinical criteria apply to all drugs in it. This is the list effective July 2026, revised July 24, 2026.

NC Medicaid, Division of Health Benefits, Preferred Drug List, effective July 2026 · source

The criteria are where the real gate is. An adult needs "A BMI greater than or equal to 30 kg/m2 OR A BMI greater than or equal to 27 kg/m2 with at least one weight-related comorbidity/risk factor/complication," with baseline weight and BMI "measured within the past 45 days" recorded on the form, and must be "currently on and will continue lifestyle modification including structured nutrition and physical activity." Renewal is the part people lose on: an adult must show "the patient has lost a total of 5% of pretreatment weight and maintains the 5% weight loss." Approval runs "6 months for the initial approval, 12 months for renewal; no limit on the number of renewals that may be provided," with quantity limits of Wegovy 3 mL per 28 days, Zepbound 2 mL per 28 days and Saxenda 15 mL per 30 days. ⚠ This document carries a DRAFT watermark and a submission footer on every page; we cite it because the December 2025 bulletin names these August 1, 2024 criteria as the ones restored, and because the state's live prior authorization form asks the same questions.

NC Medicaid Outpatient Pharmacy Prior Approval Criteria, GLP-1s for Weight Management, effective August 2024 · source

Your plan cannot make it harder. The state's own factsheet for providers says all health plans "follow the same policy as NC Medicaid Direct does today including following the same single NC Preferred Drug List (PDL)," and that they "are required to follow the same criteria when prior authorization (PA) is required to obtain a medication and cannot apply new or different PA from the PDL." So changing plans will not change the answer, and a plan asking you for something the criteria above do not require is worth questioning.

NC Medicaid Managed Care: What Providers Need to Know About Pharmacy · source

North Carolina runs two different appeal clocks and which one is yours depends on whether you are in a health plan. In managed care you appeal to the plan first, "no later than 60 days after the mailing date of the notice of adverse benefit determination," and only then to the Office of Administrative Hearings, "by no later than 120 days after the mailing date of the notice of resolution." In NC Medicaid Direct there is no plan step and the window is much shorter: "The recipient shall request a hearing within 30 days of the mailing of the notice." Thirty days and sixty days are both on this page because both are real; the notice you were sent says which one you are on.

N.C.G.S. §108D-13, North Carolina General Assembly · source · §108D-15 · §108A-70.9A