Analysis shows ACA Marketplace GLP-1 coverage shrinking

Coverage for GLP-1 weight-loss drugs under Affordable Care Act Marketplace plans keeps shrinking, according to a new analysis from the healthcare advisory group Leverage|Axiaci that was shared with Becker's and published Dec. 2, 2025 ^[1]. The number of Marketplace enrollees with coverage for these drugs for weight loss fell from 3.6 million in 2024 to 2.8 million in 2026 ^[1].

The analysis, funded by the Robert Wood Johnson Foundation, reviewed the policies of all 300 carriers offering Marketplace plans in 2026 to see whether and how they cover three drugs approved for weight management: Wegovy (semaglutide), Zepbound (tirzepatide) and Saxenda (liraglutide) ^[1].

Of those 300 carriers, only 26 offer coverage of GLP-1s for treating obesity ^[1]. Those carriers are concentrated in nine states: California, North Dakota, New York, Vermont, Pennsylvania, West Virginia, Rhode Island, Delaware and Georgia ^[1]. In California and North Dakota, every carrier offers at least some plans that cover GLP-1s ^[1]. In the other 41 states, the analysis found no Marketplace carrier covering these drugs for obesity ^[1].

The rules are tighter, too

It is not just that fewer plans cover the drugs. The plans that do have added hurdles. All but four of the 26 carriers limit coverage to people with morbid obesity, defined as a body mass index of 40 or above ^[1]. That is a higher bar than the FDA labeling threshold most people are familiar with, and it excludes many people who meet the usual clinical definition of obesity.

Every one of the carriers also requires documentation that the enrollee took part in a diet and exercise program for three to nine months before a GLP-1 request can be made, plus proof that the person was unable to lose weight during that period ^[1].

The combined effect is stark. The analysis projects that if the same 24.5 million people who were enrolled in ACA plans in 2025 re-enrolled in 2026, fewer than 10% would have GLP-1 coverage at all — and only a fraction of that group would actually meet the more restrictive 2026 requirements ^[1].

Why it matters for patients

For people who buy their own insurance through healthcare.gov or a state exchange, the practical takeaway is that a plan's drug list matters more than ever, and that coverage for obesity treatment is now the exception rather than the rule on the individual market. Two people with the same diagnosis and the same prescription can face completely different costs depending on which state they live in and which carrier they pick.

Even within the nine states listed, coverage is not automatic. A person with a BMI in the low-to-mid 30s would fall outside the criteria used by 22 of the 26 carriers ^[1]. And because all 26 require several months of documented diet-and-exercise attempts before a request, approval can take a season or more of paperwork even when a plan technically covers the drug ^[1].

The analysis looked only at coverage for obesity. It did not report on coverage of semaglutide or tirzepatide when prescribed for type 2 diabetes — products such as Ozempic, Rybelsus and Mounjaro — or for other approved uses, so nothing here should be read as describing those situations ^[1].

The source also does not explain why carriers are pulling back, does not name the 26 carriers, and does not say what enrollees pay out of pocket when a drug is covered. Those details are not yet known from this analysis.

What happens next

Open enrollment decisions made this winter determine coverage for the 2026 plan year ^[1]. Because Marketplace formularies and prior-authorization rules are set annually, the criteria described here — the BMI 40 threshold and the three-to-nine-month lifestyle documentation requirement — are what applies for 2026 in the states where coverage exists ^[1]. Whether the decline continues into 2027 has not been reported.