This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
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.
NC Medicaid remains committed to the potential of GLP-1s for the treatment of obesity; however, at this time the lack of funding for the program prohibits continued coverage for weight management purposes.
GLP-1s will continue to be covered for the indications of diabetes, reduction in cardiovascular death, heart attack and stroke in obese adults with cardiovascular disease, noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) and severe obstructive sleep apnea (OSA).
What's Changing
- Effective Oct. 1, 2025, Wegovy, Zepbound and Saxenda will be removed from the Preferred Drug List (PDL) as an off-cycle change.
- Saxenda will no longer be covered for any indication.
- The Non-Incretin Mimetics class of drugs for treatment of obesity will continue to be managed through the PDL. Drugs in the Preferred status on the PDL include: diethylpropion, phendimetrazine and phentermine. These products do not require prior approval.
Coverage of Wegovy and Zepbound will be managed through prior authorization, using clinical criteria established by the State for the below Food and Drug Administration (FDA) approved indications.
Continued Coverage for Other Indications
Wegovy
- To reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease who are obese.
- For the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults.
Zepbound
- To treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Prior Authorization Requirements
- Providers will need to obtain a new prior authorization for beneficiaries receiving Wegovy and Zepbound, effective Oct. 1, 2025.
- Current prior authorizations will no longer be valid after Sept. 30, 2025.
- Providers are encouraged to review updated clinical criteria located at: http://nctracks.nc.gov/content/public/providers/pharmacy/pa-drugs-criteria-new-format.html. Prior authorization requests can be submitted beginning Oct. 1, 2025.
There will be no changes to coverage for GLP-1 medications for the treatment of diabetes. Additionally, Weight Management (Non-Incretin Mimetics) will still be covered as listed on the PDL.
NC Medicaid Commitment
More than 3.1 million North Carolinians have health care coverage through Medicaid. We understand that these changes may place a burden on beneficiaries, their families and on providers. As public servants, we are committed to working with state and federal policymakers to ensure everyone can access affordable, quality health care.
Contact
NCTracks Call Center 1-800-688-6696