This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
In accordance with the Governor’s directive, NC Medicaid coverage for GLP-1s for the treatment of obesity is being reinstated effective Dec. 12, 2025.
Coverage of GLP-1s for Weight Management will revert to the criteria in place as of Sept. 30, 2025, restoring access to medications previously available under the NC Medicaid Outpatient Pharmacy Prior Approval Criteria GLP-1s for Weight Management, effective Aug. 1, 2024.
Providers should consider whether members have experienced a lapse in treatment, change in therapy and whether a lower starting dose is necessary.
What's Changing
- Wegovy, Zepbound and Saxenda has been added back to the Preferred Drug List (PDL) as an off-cycle change.
- Wegovy is a Preferred Product.
- Zepbound and Saxenda are Non-Preferred Products.
- Beneficiaries must try and fail the preferred agent Wegovy OR have a documented reason why they cannot take the preferred medication in order for NC Medicaid to approve Zepbound or Saxenda.
- Clinical Criteria for GLP-1s for Weight Management on NCTracks has been restored.
- Prior authorization requests for GLP-1 Weight Management drugs can be submitted under the reinstated criteria.
Key Notes for Providers
- Updated clinical criteria is located at: http://nctracks.nc.gov/content/public/providers/pharmacy/pa-drugs-criteria-new-format.html.
- For questions regarding when NC Medicaid Managed Care health plans will update their systems, contact the respective health plans directly.
- Contact information for the health plans: Health Plan Contacts and Resources webpage.
- Please review the full updated rate bulletin here: https://medicaid.ncdhhs.gov/blog/2025/12/19/medicaid-rate-reduction-reversal-update.
Continued Coverage for Other Indications
NC Medicaid continues to cover Wegovy and Zepbound for clinical indications other than weight loss based on the Food and Drug Administration (FDA)-approved indications and uses, which include:
- Wegovy
- Reduces the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight.
- Treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis in adults.
- Zepbound: Treatment of moderate to severe obstructive sleep apnea in adults with obesity.
NC Medicaid Committment
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: 800-688-6696
NC Medicaid Managed Care Health Plans: Health Plan Contacts and Resources page.