North Carolina Medicaid reinstates GLP-1 coverage for obesity

North Carolina's Medicaid program resumed covering GLP-1 medications for obesity treatment on Dec. 12, 2025, reversing a cutoff that began Oct. 1, 2025 during a state budget stalemate ^[3]. The reinstatement, ordered under a directive from Gov. Josh Stein, returned coverage to the same criteria that existed before the October cutoff and came alongside a reversal of broader Medicaid provider rate cuts tied to the funding dispute ^[3]. With North Carolina back on the list, 13 state Medicaid programs now cover GLP-1s for obesity treatment as of January 2026, according to KFF ^[1].

The back-and-forth shows how unstable this coverage can be. Sixteen state Medicaid programs covered GLP-1s for obesity as of October 2025, but California, New Hampshire, Pennsylvania and South Carolina all dropped coverage after that survey, even as North Carolina added its coverage back — netting out to 13 states nationally by January 2026 ^[1]. North Carolina itself first added obesity-drug coverage in August 2024, cut it in October 2025 citing a shortage of state Medicaid funding, and restored it less than three months later ^[3].

The numbers involved are substantial. In June 2025 alone, North Carolina Medicaid recorded more than $47.8 million in claims for GLP-1 weight-loss drugs covering 34,524 beneficiaries, or about 1.1% of the state's more than 3.1 million Medicaid enrollees — an average of roughly $1,386 per beneficiary that month ^[3]. That figure reflects claims before federal matching funds and manufacturer rebates are applied, and North Carolina's health department says the rebates are significant but not publicly disclosed ^[3]. Coverage includes Wegovy, Zepbound and Saxenda, subject to Medicaid's prior-authorization and clinical requirements ^[3].

North Carolina's separate State Health Plan, which covers more than 750,000 teachers, state employees, retirees and dependents, has taken the opposite path. It eliminated GLP-1 weight-loss coverage in January 2024, when more than 23,000 members were using the drugs at a net cost of over $800 per member per month after rebates, with projected spending exceeding $170 million in 2024 and $1 billion over six years if continued ^[3]. State officials say current prices remain unaffordable for that plan, and North Carolina's 2026 budget did not restore the benefit ^[3].

Why it matters for patients

Coverage for obesity drugs under Medicaid is optional under federal law, unlike coverage for diabetes, cardiovascular risk reduction or sleep apnea, which states must cover ^[1]. That means a North Carolina Medicaid enrollee's access to Wegovy or Zepbound for weight loss can depend on the state budget cycle rather than a stable, long-term policy. Almost four in ten adults with Medicaid have obesity, so coverage decisions like this affect a large population, but even where coverage exists, prior authorization and other utilization controls can still limit who actually gets the drugs ^[1].

Because GLP-1s remain optional and expensive for state budgets, other states have already gone the other direction. California, New Hampshire, Pennsylvania and South Carolina all ended obesity coverage after October 2025, even as North Carolina reinstated it ^[1]. Patients on Medicaid in states without this coverage generally cannot afford these drugs out of pocket, since eligibility for Medicaid requires low income ^[1].

What happens next

North Carolina lawmakers have directed the state's Division of Health Benefits to develop a broader Medicaid cost-savings plan addressing GLP-1 use, including giving managed-care plans more flexibility to control access and requiring mandatory participation in lifestyle-management programs; that plan is due to legislative oversight committees by Oct. 1, with implementation barred before July 1, 2027 ^[3]. Separately, the federal government's new BALANCE model, a five-year CMS initiative meant to lower GLP-1 prices through negotiated deals with manufacturers, is voluntary for state Medicaid programs and expected to begin in May 2026, which could reshape how states approach these coverage decisions ^[1].