North Carolina Medicaid ends coverage of GLP-1s for obesity

North Carolina Medicaid ended coverage of GLP-1 medications for obesity treatment on Oct. 1, 2025, citing shortfalls in state funding.^[1] The change affects more than 3.1 million people covered by NC Medicaid Direct and NC Medicaid Managed Care.^[1]

Under the new rule, Wegovy, Zepbound and Saxenda were removed from the state's Preferred Drug List as an off-cycle change.^[1] Saxenda, made by Novo Nordisk, will no longer be covered for any use.^[1] Wegovy and Zepbound can still be covered, but only for specific FDA-approved uses other than obesity: Wegovy for reducing the risk of cardiovascular death, heart attack and stroke in obese adults with cardiovascular disease, and for a liver condition called MASH with moderate to advanced fibrosis; Zepbound for moderate to severe obstructive sleep apnea in obese adults.^[1] Any prior authorization tied only to weight management stopped being valid after Sept. 30, 2025, and providers must request new authorizations under the updated clinical criteria starting Oct. 1.^[1] Coverage of GLP-1s for diabetes is not changing.^[1] Non-incretin weight-loss drugs such as diethylpropion, phendimetrazine and phentermine remain on the preferred list and do not require prior authorization.^[1]

The Medicaid change follows an earlier decision by North Carolina's State Health Plan, which covers state employees and retirees, not Medicaid enrollees. The State Health Plan's trustees voted in January 2025 to stop covering GLP-1s for weight loss starting in April, cutting off Wegovy, Saxenda and Zepbound.^[2] State Treasurer Dale Folwell said the plan had about 23,000 Wegovy users in 2024, with a potential cost of nearly $170 million a year, and that continuing coverage could have added more than $1 billion in costs over six years.^[2] Plan staff projected the State Health Plan would be $816 million in the red by 2027 and unable to pay bills by fall 2026 — but also calculated that without the GLP-1 cutoff, the shortfall would have topped $1.5 billion by 2027, suggesting other cost pressures were also at work.^[2]

North Carolina political leaders disagree publicly about what is driving these costs. House Speaker Tim Moore has argued that Folwell is "scapegoating" the weight-loss drugs and that Medicare Advantage cost increases and stalled negotiations with pharmacy benefit managers deserve more blame.^[2] Folwell has said the legislature underfunded the State Health Plan by $240 million and that drug manufacturers used their market power to block savings once the plan restricted new prescriptions, causing it to lose a 40% discount from its pharmacy benefit manager, CVS Caremark.^[2]

Why it matters for patients

People on NC Medicaid who were using Wegovy, Zepbound or Saxenda solely for weight loss no longer have that coverage as of Oct. 1, 2025.^[1] Coverage continues only if a patient qualifies under one of the other approved uses — cardiovascular risk reduction, MASH with fibrosis, or obstructive sleep apnea — and a new prior authorization is approved.^[1] Existing prior authorizations tied to obesity treatment are no longer valid, so patients and prescribers need to reapply under the new criteria if they believe another qualifying condition applies.^[1] Medicaid enrollees using these drugs for diabetes are not affected.^[1] The sources do not say how many NC Medicaid enrollees were using GLP-1s for obesity before this change, so the exact number of people losing coverage is not yet known.

What happens next

Providers could begin submitting new prior authorization requests under the updated criteria as of Oct. 1, 2025.^[1] Separately, the State Health Plan's board of trustees was expected to review options for its own budget shortfall at an October 2024 meeting, though the sources do not describe any outcome from that discussion or any plan to restore weight-loss coverage.^[2] A new state treasurer is due to take over oversight of the State Health Plan in 2025 after that November's elections, and no resolution to the funding dispute between Folwell and Moore had been reported as of publication.^[2]