GLP-1 Insurance Coverage 2026: Medicare, Medicaid, Commercial, Tricare, VA, and FEHB Explained

Coverage for GLP-1 weight loss drugs is the most fragmented category in US pharmacy benefits. Medicare Part D is barred by federal statute from covering any drug used for weight loss, with one narrow exception that opened in 2024 for Wegovyprescribed to reduce cardiovascular risk. Medicaid coverage varies state by state and only a minority of state programs cover GLP-1s for obesity. Commercial coverage depends entirely on the employer's plan design. This article walks through each payer category using only primary sources — the federal statute, FDA labels, CMS guidance, the SELECT and FLOW trial publications, the KFF Medicaid tracker, the Mercer national employer survey, and OPM's FEHB carrier letter.

1. The federal statutory framework

Medicare Part D is governed by 42 U.S.C. § 1395w-102. Section (e)(2)(A) of that statute incorporates the list of drugs that may be excluded from Medicaid coverage under Social Security Act § 1927(d)(2), which includes “agents when used for anorexia, weight loss, or weight gain.” That statutory exclusion has applied since Part D launched in 2006 and is the legal foundation for every Medicare GLP-1 coverage question^[1]. Congress has not amended this provision.

2. The one current Medicare Part D pathway: Wegovy for cardiovascular risk reduction

On March 8, 2024, the FDA approved a supplemental indication for Wegovy (semaglutide 2.4 mg) to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight, with no requirement for a type 2 diabetes diagnosis ^[3][4]. The approval was based on the SELECT trial, a randomized, double-blind, placebo-controlled outcomes study of 17,604 adults with preexisting cardiovascular disease and a BMI of 27 or greater but no diabetes. SELECT reported a primary MACE event in 6.5% of the semaglutide arm versus 8.0% of the placebo arm (hazard ratio 0.80; 95% CI 0.72 to 0.90; P<0.001) over a mean follow-up of 39.8 months^[5].

Twelve days later, on March 20, 2024, CMS issued an HPMS memo clarifying that an anti-obesity medication that subsequently receives FDA approval for an additional medically accepted indication may be considered a Part D drug for that specific use. CMS specifically noted that Wegovy, having received the cardiovascular risk reduction indication, may be covered by Part D plans when prescribed to reduce MACE risk in adults with established cardiovascular disease and obesity or overweight ^[2].

The CMS guidance has four important limits:

• It is permissive, not mandatory. Part D plans maycover Wegovy for the cardiovascular indication; they are not required to.
• It applies only to Wegovy and only to the cardiovascular risk reduction indication. It does not extend to Zepbound, Saxenda, or any other anti-obesity GLP-1, none of which has a non-weight-loss FDA indication that would qualify them as a Part D drug for that use.
• It does not cover Wegovy when prescribed for the chronic weight management indication alone. A Part D plan that covers Wegovy under this pathway can apply prior authorization to confirm the prescription is for MACE reduction in an eligible patient.
• It does not change the underlying statutory exclusion at 42 U.S.C. § 1395w-102(e)(2)(A). Drugs used for weight loss remain excluded.

3. The Ozempic kidney pathway (separate from weight loss)

On January 28, 2025, the FDA approved a supplemental indication for Ozempic (semaglutide injection 0.5 mg, 1 mg, and 2 mg) to reduce the risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death in adults with type 2 diabetes and chronic kidney disease ^[6]. The approval was based on the FLOW trial, which randomized 3,533 adults with type 2 diabetes and CKD to semaglutide 1 mg weekly versus placebo and reported a 24% relative reduction in the primary composite kidney outcome (hazard ratio 0.76; 95% CI 0.66 to 0.88; P=0.0003) ^[7].

Because the underlying indication is type 2 diabetes plus CKD, Ozempic for this use falls outside the Part D weight-loss exclusion entirely. Medicare Part D plans cover Ozempic for eligible T2D patients (with or without CKD) as a standard diabetes medication, subject to plan-level prior authorization. The same logic applies to Mounjaro (tirzepatide) for type 2 diabetes. Neither drug is covered by Part D when prescribed for chronic weight management.

4. Medicaid: state-by-state variation

State Medicaid programs make their own decisions about anti-obesity drug coverage. KFF maintains a public tracker of which fee-for-service Medicaid programs cover GLP-1 drugs for obesity. As of KFF's 2024 reporting, approximately 13 state Medicaid programs covered at least one GLP-1 drug for the obesity indication, and most of those imposed utilization controls including prior authorization and BMI thresholds ^[8]. KFF also reported that nearly two-thirds of responding state programs cited cost as a factor in their coverage decision.

All 50 state Medicaid programs cover Ozempic, Mounjaro, and Rybelsus for type 2 diabetes (subject to prior authorization and preferred drug list rules). The state-by-state divergence is entirely about the obesity indication.

Because state coverage decisions can change with each legislative session or pharmacy bulletin, the only reliable way to confirm current coverage in a specific state is to check that state Medicaid program's preferred drug list and the most recent KFF tracker entry. We do not list individual state policies in this article because state decisions move faster than any static page can track accurately.

5. Commercial insurance: variable, employer-driven

Commercial coverage of GLP-1 anti-obesity drugs depends on the employer's plan design. The Mercer National Survey of Employer-Sponsored Health Plans 2024 (n=2,194 employers, fielded June through August 2024) reported that 44% of large employers (≥500 workers) covered GLP-1 drugs for obesity in 2024, up from 41% in 2023. Among the largest employers (≥20,000 workers), 64% covered GLP-1s for obesity, up from 56% in 2023^[10]. Mercer also reported that nearly all employers offering coverage applied prior authorization or other utilization management.

The Mercer figures describe coverage by employer count weighted to the larger end of the market and should not be confused with KFF's separate Employer Health Benefits Survey, which uses a different sampling universe and reports lower prevalence in the broader firm population. When citing “X% of employers cover GLP-1s,” always check which survey, which firm-size cutoff, and which year.

For commercial plans that do cover GLP-1s for chronic weight management, prior authorization criteria typically include a BMI threshold of 30 or higher (or 27 or higher with a weight-related comorbidity such as hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea, or established cardiovascular disease), documentation of prior diet and exercise efforts, and a Letter of Medical Necessity from the prescriber. Specific criteria vary by plan and the only authoritative source for any patient is their own plan's coverage policy document.

The CVS Caremark template formulary change

Effective July 1, 2025, CVS Caremark removed Zepbound (tirzepatide) from its standard control, advanced control, and value template formularies, retaining Wegovy (semaglutide 2.4 mg) as the preferred GLP-1 for chronic weight management on plans that use those templates ^[11]. CVS Caremark framed the decision as a cost-management measure tied to its ability to negotiate net price on Wegovy. Patients on plans using a CVS Caremark template formulary who had previously been stable on Zepbound generally needed to switch to Wegovy or pursue a formulary exception based on documented intolerance or insufficient response to Wegovy. Note that not every CVS Caremark client uses the standard templates; some large employers maintain custom formularies that are not affected by the template change.

6. Tricare

Tricare Prime and Tricare Select beneficiaries (active duty and dependents) have access to GLP-1 weight management drugs through the Tricare Uniform Formulary, subject to the prior authorization criteria published by the Defense Health Agency. Tricare For Life beneficiaries are Medicare-eligible and their pharmacy coverage is delivered through Medicare Part D, which means the federal Part D weight-loss exclusion described above applies to them as well: Tricare For Life does not provide a separate weight-loss-drug benefit that bypasses the Medicare statute.

Tricare prior-authorization criteria and uniform formulary status can change with each Pharmacy and Therapeutics Committee meeting. The authoritative source is the current Tricare Formulary Search tool and the corresponding DHA criteria document for each drug. We do not cite specific Tricare termination dates or formulary tier placements in this article unless they appear in a current DHA document.

7. Federal Employees Health Benefits (FEHB)

OPM Carrier Letter 2023-01 (“Prevention and Treatment of Obesity”) requires FEHB carriers to cover at least one anti-obesity drug from the GLP-1 class plus at least two additional oral anti-obesity drugs ^[12]. That requirement establishes a coverage floor across all FEHB plans, but it does not set tier placement, copay levels, prior authorization criteria, or which specific GLP-1 each carrier chooses to cover. Those details vary carrier by carrier and plan year, and the only authoritative source for any specific FEHB plan is the plan's current Rate Information (RI) brochure for that plan year. Federal employees comparing plans during Open Season should pull each candidate plan's brochure and search it for “Wegovy,” “Zepbound,” “Saxenda,” “semaglutide,” and “tirzepatide” before deciding.

8. The Treat and Reduce Obesity Act (TROA)

The Treat and Reduce Obesity Act would amend the Medicare Part D statute to permit coverage of FDA-approved anti-obesity medications. TROA has been introduced in Congress repeatedly since 2012 and was reintroduced in the 119th Congress as S.1973 (Senate) and H.R.4231 (House) in 2025 ^[13]. TROA has not been enacted into law in any Congress. Until and unless Congress passes TROA or a similar amendment, the Part D weight-loss exclusion at 42 U.S.C. § 1395w-102(e)(2)(A) remains in effect.

9. How to find out what your specific plan covers

The fastest way to know what you are actually eligible for:

1. Look up your plan's formulary. Every insurance plan publishes a drug formulary listing covered medications and their tier placement. Search for “Wegovy,” “Zepbound,” or “Saxenda” by name. If the drug is listed, the formulary will note prior authorization requirements and the tier copay.
2. Call the member services number on your insurance card. Ask: “Is Wegovy or Zepbound on my formulary for chronic weight management? What are the prior authorization criteria? What would my copay be?”
3. Talk to your prescriber. Many prescribers have benefits navigators or prior-authorization specialists who can submit the PA on your behalf.
4. Use a manufacturer savings card if eligible. With commercial insurance and an approved PA, the Wegovy and Zepbound savings cards reduce patient cost substantially. Eligibility rules vary and Medicare/Medicaid beneficiaries are excluded by federal anti-kickback rules.

Important disclaimer

This article reflects the publicly available state of coverage as of the publication date based on the primary sources cited above. Insurance coverage changes frequently and the specific terms of any individual plan may differ from the general categories described here. Always verify coverage with your specific insurance plan's member services line and your prescriber before making decisions about your therapy. Weight Loss Rankings does not provide medical or financial advice.

Related research and tools

For the commercial-insurer PA guide quintet — verbatim primary-source PA criteria from the five largest commercial payers — see our Aetna GLP-1 PA guide (bulletins 4774-C / 6947-C / 1227-C / 5468-C / 2439-C; CVS Caremark July 2025 Wegovy-preferred swap), Cigna GLP-1 PA guide (IP0206 11-condition comorbidity list; 130-day non-metformin step rule), Anthem GLP-1 PA guide (CC-0188 framework; CarelonRx PBM; 14-state BCBS variation; VA Medicaid BMI > 40 threshold; CA Medi-Cal 01/01/2026 exclusion), UnitedHealthcare GLP-1 PA guide (CDG CS10028.1; OptumRx January 2025 Wegovy-preferred update; CDG CS10191 for Foundayo — first of the four to publish Foundayo criteria; NY + MA state mandate overrides — the largest commercial insurer in the US), and BCBS FEP GLP-1 PA guide (OPM Carrier Letter 2023-01 coverage mandate; CVS Caremark dedicated FEP formulary; Standard/Basic/FEP Blue Focus plan options; unique federal disputed-claims appeal pathway through OPM; no state-level variation; ~5.5M federal employees and retirees — closes the commercial PA quintet).

For employer-by-employer coverage data on the large US employers we track, see our insurance employer checker. For the cost comparison if you end up self-paying, see our GLP-1 savings calculator. For the FLOW kidney trial that opened the Ozempic CKD pathway, see our FLOW trial deep-dive. For the broader insurer-by-insurer formulary picture, see our GLP-1 coverage audit. For state-by-state Medicaid deep-dives, we’ve published verbatim-primary-source coverage articles on the four largest state Medicaid programs: Texas Medicaid (HHSC/Acentra) — explicit non-coverage anchored to the Superior HealthPlan “Non-Covered Benefit” provider notice; California Medi-Cal Rx — the state-reversal narrative (Wegovy + Zepbound for weight loss removed January 1, 2026 per the 2025-26 State Budget; Wegovy re-added April 1, 2026 for MASH only with ICD-10 K76.0 / K75.8); New York Medicaid (NYRx) — the strongest-evidenced exclusion state, triple-anchored on federal 42 USC § 1396r-8(d)(2)(A) + state regulation 18 NYCRR § 505.3(g)(3) + the NYRx contractor brand-naming “Ozempic, Wegovy, and Mounjaro are excluded from coverage for weight loss indications;” and Florida Medicaid (AHCA SMMC) — the silent-exclusion case where coverage is operational by absence in the AHCA PDL plus the verbatim plan-level deferral statements from Sunshine Health, Humana Healthy Horizons, Simply Healthcare, Molina, and Aetna Better Health of Florida; and Illinois Medicaid (HFS) — the strictest-exclusion case in the cluster, doubly-anchored on 89 IAC § 140.441(b) (“Anorectic drugs or combinations including such drugs”, last amended May 30, 2014 — five months before Saxenda's December 2014 FDA approval) plus the HFS PDL absence with zero Wegovy / Zepbound / Saxenda / Foundayo entries and no cardiovascular, MASH, or OSA carve-back-in pathway published; and Ohio Medicaid (ODM / Gainwell SPBM) — triple-anchored explicit non-coverage with a January 7, 2026 P&T-meeting carve-back-in: the committee created a new “Metabolic Modifiers: GLP-1 Agonists for Non-Obesity Indications” drug class and adopted Wegovy as Preferred for the FDA MACE and MASH indications — broader than California's MASH-only re-add — while keeping Ohio's underlying weight-loss exclusion fully in force (the Wegovy MACE PA criteria require A1C < 6.5% and explicitly exclude any patient with type 1 or type 2 diabetes, stricter than the FDA MACE label); and Georgia Medicaid (DCH / multi-PBM stack) — the dual-level operational case where the federal weight-loss exclusion is operationalized at TWO simultaneous levels: a Statewide PDL omission (the “WEIGHT MANAGEMENT AGENTS” class slot exists in the schema but contains no covered drugs for adults — “No changes” through both Jul 2025 and Jan 2026 P&T cycles) plus a Peach State Health Plan CMO Member PDL with the verbatim “Drugs prescribed for weight loss” exclusion language — the most explicit member-facing CMO exclusion in the cluster, with no parallel state Administrative Code rule (a verified absence at Georgia Department 350); and Pennsylvania Medicaid (DHS / OptumRx) — the policy-reversal case (the inverse of California): Pennsylvania TERMINATED GLP-1 obesity coverage on January 1, 2026 after 34 months of coverage, triple-anchored on MAB2025112403 (Nov 24, 2025 DHS Medicaid Bulletin) plus 55 Pa.B. 8828 (Dec 27, 2025 Pennsylvania Bulletin) plus 55 Pa. Code § 1121.54 (amended Jan 2, 2026 effective Jan 3, 2026), with a documented $836M/year savings to FY26-27 as the budget rationale and Saxenda placed under a total exclusion (the strongest single-drug exclusion in the cluster, creating EPSDT tension for adolescents under the FDA pediatric obesity label); and North Carolina Medicaid (NCDHHS DHB) — the FIRST POSITIVE-COVERAGE state in the cluster and the structural inverse of Pennsylvania's policy-reversal pattern. NC completed a full on-off-on cycle within 16 months (covered August 1, 2024 → terminated October 1, 2025 → reinstated December 12, 2025 by gubernatorial directive). As of the January 1, 2026 PDL (Revised 12.10.2025 Off Cycle Change), Wegovy is listed as Preferred for the chronic-weight-management indication — the only such Preferred listing across the 9-state cluster. PA and NC share the same October 2025 – January 2026 calendar window for their reversal decisions but reached opposite outcomes: PA terminated and stayed off; NC terminated and reinstated in 73 days. Two more state cases round out the cluster: Michigan Medicaid (MDHHS) — partial retainment with the most restrictive gate in the cluster (BMI ≥ 40 floor + the uniquely-Michigan bariatric-surgery-avoidance prescriber attestation + 5-class step therapy through every PDL-preferred non-GLP-1 anti-obesity class), with authority anchored in appropriations boilerplate (Public Act 22 of 2025) rather than regulation; and New Jersey FamilyCare (DMAHS) — the dual-authority explicit-exclusion case anchored in N.J.A.C. § 10:51-1.13(a)(2) plus the November 2025 DMAHS GLP-1 Memo, distinguished by unprecedented public fiscal transparency (the only state with a DMAHS-published memo to the Legislature specifying SFY 2026 gross expenditures, federal share, manufacturer rebates, and net state-fund cost) and a structural cross-jurisdictional inverse of NC: NJ's State Health Benefits Program covers non-diabetic GLP-1s while NJ FamilyCare categorically excludes them; and Washington Medicaid (Apple Health) — the YMYL-trap exemplar of the 14-state series and the state that pioneered the indication-anchored carve-out pattern. Washington is classified by KFF as one of 13 covering states while simultaneously publishing the verbatim phrase “is not covered by Apple Health for weight loss” in its own active clinical policies (HCA Medical Policies 61.25.20.AA-4 and 61.25.25.AA-1). The resolution is indication-anchored coverage: WA covers Wegovy for MACE (BMI ≥ 27, effective July 1, 2024 — 18 months before Ohio's analogous carve-out) and MASH, plus Zepbound for OSA (BMI > 30) — all non-weight-loss FDA indications — while the WAC 182-530-2100(1)(b)(i) weight-loss exclusion remains fully operative. WA has the broadest non-weight-loss carve-out menu in the cluster (MACE + MASH + OSA). Active reform legislation: SB 5353/HB 1326 (“Diabetes prevention and obesity treatment act”) has been pre-filed in two consecutive sessions (2025, 2026) and remains in Senate Health & Long-Term Care committee. The sharpest contrast with WA is Nevada Medicaid (Nevada Health Authority) — Pattern #31 and the most restrictive Wegovy-CV state in the series. Nevada has exactly one carve-out (Wegovy MACE, Web Announcement 3337, April 22, 2024) and has taken no SSSB action on MASH or Zepbound-OSA for 19 months despite the broader national pattern shifting. SB 244 (2025), which would have mandated FDA-approved weight-management GLP-1 coverage effective January 1, 2026, died in money committee on June 3, 2025 after DHCFP projected a $165.4 million biennium cost ($64.3 million General Fund). Finally, Tennessee Medicaid (TennCare) — the positive-coverage expansion case and the only state in the cluster that ADDED obesity-indication coverage from a prior categorical-exclusion baseline. Effective August 1, 2025 via Sequence 10-34-25 (a four-rule TennCare amendment funded by 2025 Public Chapter 530 with a $2.7M annual projection), TennCare now covers all 10 traditional anti-obesity medications without prior authorization (only quantity limits) and runs a single GLP-1 PA form covering five indications simultaneously (T2D, obesity, MACE, OSA, MASH) — the broadest indication selector in the series. Counterintuitively, the State of Tennessee employee plan (Caremark formulary, October 1, 2025) does NOT cover Zepbound while TennCare DOES — the inverse of NC, where the State Health Plan terminated GLP-1 obesity coverage while Medicaid reinstated. And Arizona Medicaid (AHCCCS) — the agency-manual explicit exclusion case anchored in the AHCCCS Fee-For-Service Provider Billing Manual Chapter 12 (Pharmacy Services) item #13, verbatim “Medications used for weight loss treatment.” Structurally distinct from every other anchor type in the cluster: NOT a state regulation (R9-22-209 silent on weight-loss drugs), NOT a PDL omission, NOT a transition bulletin, NOT a budget reversal — operationally the most direct primary-source citation in the series. AZ uses a unique dual-vendor PBM architecture: OptumRx adjudicates FFS pharmacy claims (BIN 001553) while Prime Therapeutics is the PDL / supplemental-rebate vendor presenting class reviews to the AHCCCS P&T Committee. UHC AZ's PDL contains a documented internal inconsistency that this article walks through with both verbatim quotes: Wegovy listed under “Anti-Obesity Agents — Drugs for Weight Loss” (PA + QL) while “Anti-obesity agents” is simultaneously named in the Plan Exclusions section — probably operationalized via FDA non-obesity indication PA review, the only AZ-level operational pathway to any Wegovy prescription and contractor-specific to UHC only. Most recently, Massachusetts Medicaid (MassHealth) — the two-phase termination case that closes a 30-month positive-coverage window (Jan 2024 → June 30, 2026) and converges with WA/OH on indication- anchored MACE + MASH + OSA carve-outs starting Phase 2 on July 1, 2026. MassHealth presents the direct mirror-image of TN's expansion in the same calendar quarter (TN added Aug 1, 2025; MA terminates Jul 1, 2026 — the 12-month inversion). Procedurally distinctive: MA's 130 CMR 406.413(B) regulatory amendment is “anticipated forthcoming” — Pharmacy Facts #271 announced the termination operationally BEFORE the regulation was promulgated (distinct from PA's MAB2025112403, which had 55 Pa. Code § 1121.54 already in place). The Healey administration layered six separate fiscal instruments (FY26 supp H.4251 § 8 GIC mid-year plan-change authority + GIC vote + FY27 budget + MassHealth admin termination + HSN 2025 termination + DOI commercial guidance) with a documented $27.5M FY26 GIC + ~$15M MassHealth FY27 savings projection — the most comprehensive coordinated state-level GLP-1 retrenchment yet documented. And Indiana Medicaid (IHCP) — the Zepbound-preferred anomaly case anchored in 405 IAC 5-24-3(b)(1) (“Anorectics or any agent used to promote weight loss”). Indiana provides the cleanest illustration of PDL preferred status ≠ clinical coverage: Zepbound is listed as PREFERRED on the December 1, 2025 IHCP SUPDL (a procurement/rebate decision driven by the Lilly contract) while ALL adult chronic- weight-management indications remain excluded. The HB 1202 Fiscal Note (LSA, Jason Barrett, Jan 3, 2025) contains the most operationally direct adult-exclusion statement found in the entire 16-state cluster: verbatim “Indiana Medicaid does not currently cover weight management medication to members age 21 or older.” Most other states' exclusions must be inferred from PDL omission or regulatory citation; Indiana's is stated in its own legislative-fiscal-services-agency analysis. EPSDT pediatric carve-in via IHCP Bulletin BT2023148 (Oct 31, 2023) carves Wegovy/Saxenda in for under-21 obesity treatment; adults remain excluded. Indiana's state-employee plan dropped GLP-1 weight-loss coverage Jan 1, 2026 — parallel to PA Medicaid termination (different program, same calendar window). And Maryland Medicaid (MDH HealthChoice) — the HCPCS J3490 medical-benefit pathwaycase + dual-indication carve-out (Wegovy ASCVD + Wegovy MASH). Maryland is the ONLY state in the cluster where Wegovy non-weight- loss coverage operates as a physician-administered drug under the medical benefit (HCPCS J3490, priced per invoice) rather than as a retail pharmacy benefit. **Wegovy is absent from Advisory 282 entirely** — prescribers must bill via medical claims, and a High-Cost Low-Volume risk corridor removes Wegovy ASCVD/MASH costs from MCO capitation (MCOs invoice MDH quarterly), producing mechanically uniform coverage across all 9 HealthChoice MCOs without any MCO formulary-deferral language. The cleanest verbatim agency-attested adult-exclusion statement found in the entire 17-state primary-source sweep is the MDH Pharmacy News & Views (Nov 2025): “In accordance with COMAR 10.09.03.05 (A)(14), prescriptions for weight control indications will not be covered at this time.” Active 2026 RS legislation SB 0496 / HB 0813 (“Authorization — not Mandate”) passed both chambers and reached conference committee April 9, 2026; effective Jan 1, 2027 if enacted, contingent on CMS SPA. Distinct from prior coverage- mandate bills (2025 SB 876 / HB 1489 both died in committee). Finally, Virginia Medicaid (Cardinal Care) — the highest published BMI threshold in the cluster case (BMI > 40 floor + BMI > 37 with comorbidity) plus a two-level nested step-therapy(traditional non-GLP-1 weight-loss drug → Saxenda → Wegovy/Zepbound) and forced PBM consolidation underwayvia HB 2610 / SB 875 (signed by Youngkin 2025) requiring DMAS to procure a SINGLE PBM for ALL Medicaid populations by July 1, 2026 with a projected $39M annual savings — VA is the FIRST state in the cluster mid-PBM-consolidation. Active 2026 amendments (SB30 Item 291 #5s + HB30 Item 291 #9h) propose a $245/month BALANCE-conditional pricing pathway that would lower the BMI floor to FDA-label-aligned thresholds (BMI ≥ 35 / ≥ 30+comorbidity / ≥ 27+pre-diabetes/CVD/OSA) IF the price target is achieved — otherwise the current BMI > 40 floor continues. The MASH SA Form is NEW as of October 16, 2025 P&T meeting. Notable YMYL trap: the 2024 budget rider was DRAFTED with an “excluding GLP-1” clause that was REMOVED by floor amendment 288 #3h before enactment — December 2024 news coverage describing the original draft is now misleading. 12 VAC 30-50-520 has been unamended since 1999 and references the “Social Security Administration in effect on April 7, 1999” disability standard, completely superseded operationally by budget riders but never formally re-promulgated. And Wisconsin Medicaid (BadgerCare Plus) — the 3rd positive-coverage state in the cluster (after NC and TN), uniquely paradoxical as “most permissive in scope, most restrictive in continuity.” 6 AOMs covered continuously since March 2023 with FDA-label-aligned BMI thresholds — but with a published 2-lifetime-attempts cap across all 6 covered AOMs (discontinue any 2 for any reason and future PA is permanently denied), a unique BMI < 24 renewal-revocation rule (succeeding on therapy can revoke coverage at next renewal — the success-paradox documented nowhere else in the cluster), NO PBM intermediary (DHS Division of Medicaid Services administers pharmacy claims directly through ForwardHealth with Gainwell as MMIS operator only), and explicit AOM coverage for dual eligibles enrolled in Medicare Part D(Update 2025-16 verbatim — the only state in the cluster filling the federal Part D AOM exclusion gap). Wisconsin is also the cleanest case study of the “Medicaid covers, employer plan doesn't” inversion: BadgerCare Plus has covered 6 AOMs continuously since March 2023, while the GIB/ETF state-employee plan (Navitus PBM) doesn't start AOM coverage until January 1, 2027. Finally, Minnesota Medicaid (MA / MinnesotaCare) — the 4th positive-coverage state with the most institutional entrenchment but most active legislative threat. Minnesota is the FIRST state in the cluster with a dedicated “Weight Management Agents” PDL class (others fold weight loss into hypoglycemic or specialty classes), with Saxenda and Wegovy listed as Preferred (12-1-2024 update) — an institutional entrenchment marker. But HF4142 (Nadeau, Gander, Rehrauer; introduced 3/9/2026; laid over 3/25/2026 by House Health Finance & Policy Committee with possible omnibus inclusion) is a hostile single-section bill that would amend § 256B.0625 subd. 13d to add “drugs or active pharmaceutical ingredients when used only for weight loss” as a new exclusion effective Jan 1, 2027 or upon federal approval. Asymmetric sponsorship (no Senate companion). Like Wisconsin, Minnesota uses a FFS-direct no-PBM architecture(DHS administers MA pharmacy claims directly through MN-ITS). Unique in the cluster: tirzepatide is listed in two PDL classes simultaneously — Mounjaro under Hypoglycemics (Non-Preferred, T2D label) and Zepbound under the dedicated Weight Management Agents class (Non-Preferred, weight management label) — the cleanest FDA-indication-anchored PDL architecture in the cluster. Finally, Kentucky Medicaid (DMS / MedImpact) — the nullified-amendment exclusion stateand the cleanest counter-example to Tennessee's expansion in the entire 21-state cluster. Beshear's administration formally proposed amending 907 KAR 23:010 (filed Sep 9, 2025; public hearing Nov 24, 2025) to add GLP-1 chronic-weight- management coverage. SB 65 (Sen. Stephen West, R-Paris) was vetoed by Beshear April 6, 2026; Senate overrode 32-6, House overrode 79-19; bill became law April 14, 2026 — nullifying the amendment AND prohibiting DMS from re-promulgating until June 1, 2027. KY also has the most permissive Wegovy MACE pathway in the cluster (BMI ≥ 27 — FDA SELECT label minimum) but with a uniquely-Kentucky T2D exclusion across all carve-out pathways (T2D patients are routed to the GLP-1 RA T2D class, NOT the MACE/MASH/Zepbound-OSA pathways). KEHP state-employee plan retains GLP-1 weight-loss coverage while KY Medicaid does not — the structural inverse of Indiana (where state-employee plan dropped coverage while Medicaid retained an EPSDT pediatric carve-in). And Missouri Medicaid (MO HealthNet) — the 5th positive-coverage state in the cluster (after NC, TN, WI, MN), uniquely structured to demote Wegovy from chronic weight management (verbatim PA Form 2575-053: “Wegovy for the reduction of excess body weight or maintenance of weight reduction long term is not covered by MO HealthNet” — restricted to MACE-reduction + noncirrhotic MASH F2/F3 only) while elevating Foundayo (orforglipron) to Preferred on the 2026-05-01 PDL — the FIRST state in the cluster to formally place orforglipron as preferred. Missouri also features a uniquely-MO antipsychotic- induced weight gain Zepbound indication checkbox on the PA Form (no other state's PA form lists this), dual federal model LOIs submitted Jan 20, 2026 (BALANCE Model + GENEROUS Model — first in series to file LOIs to BOTH federal models), and a unique dual-vendor PBMarchitecture (Conduent operates SmartPA point-of-sale + DPAC clinical-edit drafting; Gainwell operates PDL preferred/non- preferred classification + supplemental rebate negotiation). Coverage launched Jan 9, 2025. Statewide pharmacy carve-out from all 3 MCOs since Oct 1, 2009. NO active 2026 hostile Medicaid legislation (SB 1606 amends Chapter 376 commercial insurance, NOT Chapter 208 Medicaid). And Alabama Medicaid (AMA / Acentra) — the PDL-enumerated OSA-only Zepbound carve-out + off-PDL Cardiac-Agents Wegovy MACE case. AL is the first state in the cluster with an in-PDL OSA-only Zepbound footnote within the Incretin Mimetics class (KY achieves similar OSA-only coverage but via stand-alone PA PDFs, NOT in-PDL). Wegovy is administered through a Cardiac Agents PA section — NOT a GLP-1 class, NOT an Anti-Obesity class — the most architecturally fragmented Wegovy MACE pathway in the cluster. PBM = Acentra (SAME as TX, the only repeat in the 23-state cluster) + Gainwell as claims fiscal agent. Statewide FFS pharmacy benefit with no MCO carve-out (ACHN provides care-coordination only). HJR162 + SJR60 are non-binding study resolutions with no coverage mandate. Notable YMYL trap: the Real Chemistry/Opelika Observer Dec 2024 “Yes coverage” classification is misleading — the claims-data observed Wegovy reimbursement is MACE-only, NOT chronic-weight-management. With 39.2% adult obesity prevalence (5th-highest in nation, CDC BRFSS 2023) + non-expansion-state status + categorical regulatory exclusion, Alabama presents the cluster's starkest structural mismatch between disease burden and Medicaid coverage. And Oklahoma SoonerCare (OHCA / PMC) — the triple-carve-out + university-PA-administeredcase. OK is the only state in the 24-state cluster with PA infrastructure operated by a state university (Pharmacy Management Consultants at the University of Oklahoma College of Pharmacy under OHCA contract, drafting every PA criterion the OHCA DUR Board votes on, evaluating 8,000+ PA requests per month). OK has the MOST DUR-Board-approved carve-outs in the cluster (4): Wegovy CV-only + Wegovy MASH-only + Zepbound OSA-only + Imcivree monogenic-obesity-only (the cluster's only DUR-Board-approved Imcivree pathway, narrowly scoped to pediatric age 2+ with POMC/PCSK1/LEPR deficiency or Bardet-Biedl syndrome). OK's SoonerCare AOA quarterly approval rate is documented at 7.8% (June 2025: 8 of 102 PA requests). T2DM diagnosis gate enforced at the PA-criteria level (added July 2025) — meaning Mounjaro and Ozempic are blocked for off-label chronic-weight-management at the operational PA level, NOT just at the PDL level. With this OK ship, the cluster reached 24 articles + 24 distinct documented coverage patterns — 48% of the 50-state series. The series now extends to Pattern #25: New Hampshire Medicaid (DHHS) — the third state in the KFF January 2026 four-state elimination cluster (CA #2 + PA #7 + NH #25 + SC pending). NH’s Pattern #25 is uniquely distinguished by the leanest termination paper trail in the series (a single one-page DHHS Provider Notification dated October 9, 2025 — no NH RSA, no He-W rule amendment, no P&T/DUR Board action) combined with a four-indication carve-out (T2DM + MACE + OSA + MASH) that matches Massachusetts’s prospective Phase 2 architecture on all four dimensions — but without any published indication-specific PA criteria documents for the three non-T2DM indications. NH Healthy Families Clinical Policy NH.PMN.50 explicitly names “Medication request is not a GLP-1 receptor agonist” as criterion 1 in every anti-obesity PA ladder. SB 455 (the 2026 restoration vehicle) was blocked 13–2 at the House Commerce Committee. And South Carolina Medicaid (Healthy Connections / Magellan–Prime Therapeutics sPDL) — Pattern #26 and the fourth/final state in the KFF four-state elimination cluster, closing the full cluster map (CA #2 + PA #7 + NH #25 + SC #26). SC terminated January 1, 2026 after only 14 months of coverage (November 2024 – December 2025) — the SHORTEST GLP-1 obesity coverage window in the 26-state series. SC’s termination is anchored not in a published Medical Assistance Bulletin or regulatory amendment but in a 4-sentence “State Updates” paragraph from Dr. Kevin Wessinger in the November 5, 2025 P&T Committee minutes + the SCDHHS Pharmacy Services Provider Manual January 1, 2026 categorical “Weight control products” exclusion + the May 1, 2026 sPDL omission of Wegovy/Saxenda/Zepbound. SC is also the only state simultaneously in both the KFF elimination cluster AND the southern non-expansion exclusion cluster (AL + FL + GA + SC + TX) — the most taxonomically distinctive state in the 26-state series. With SC, the series reaches 26 articles + 26 distinct documented coverage patterns — 52% of the 50-state series; the KFF four-state elimination cluster is now fully documented. And Colorado Medicaid (Health First Colorado / HCPF / MedImpact) — Pattern #27: the dual-carve-out regulatory-exclusion state with permanent triple-indication positive coverage (Wegovy CV BMI ≥ 25 + Wegovy MASH + Zepbound OSA) + SB 25-048 large-group commercial mandate with explicit Medicaid/CHP+ carve-out. Colorado is the first state in the 27-state series to enact a statewide commercial anti-obesity medication coverage mandate while deliberately excluding its own Medicaid program from that mandate in the same bill. Colorado also carries the most permissive Wegovy-CV BMI threshold in the series (BMI ≥ 25 vs. ≥ 27 in WA, OK, and AL), the Wegovy oral tablet PDL entry (shared only with Washington), and a PBM transition (Prime Therapeutics → MedImpact effective April 1, 2026) contemporaneous with this article's publication window. With CO, the series reaches 27 articles + 27 distinct documented coverage patterns — 54% of the 50-state series. And Louisiana Medicaid (Healthy Louisiana / LDH / ULM College of Pharmacy PA) — Pattern #28: the expansion-state dual-PDL-listed carve-out state — first Deep South state to expand Medicaid (July 1, 2016 via JBE 16-01), and the only state in the series to enumerate BOTH Wegovy AND Zepbound on the same Single PDL with PATIENT TREATMENT AGREEMENT. Wegovy for CV only (age ≥ 45, BMI ≥ 27, established CVD, no T1DM/T2DM); Zepbound for moderate-to-severe OSA only (AHI ≥ 15, BMI ≥ 30, no T1DM/T2DM). ULM College of Pharmacy FFS PA — 2nd state-university PA infrastructure in series after OK. Post-Oct-2025 5-PBM model (per IB 25-27). Active SB 433 expansion: passed Senate 31-0 on April 29, 2026; House pending; effective January 1, 2027 if enacted. LDH Secretary Greenstein: ‘an absolute life changer.’. With LA, the series reaches 28 articles + 28 distinct documented coverage patterns — 56% of the 50-state series. And Oregon Medicaid (Oregon Health Plan / OHA / DURM–OSU / 15 CCOs) — Pattern #29: the HERC Prioritized List Guideline Note 5 evidence-based-coverage exclusion state — the only state in the 29-state series where the operative AOM exclusion mechanism sits in an evidence-based coverage list rather than a pharmacy-benefit regulation. HERC Guideline Note 5 at Line 317 verbatim: “Pharmacological treatments and devices ... for obesity are not intended to be included as services on this line or any other line on the Prioritized List.” Three FDA-label carve-outs: Wegovy CV (established CVD, BMI ≥ 25, diabetes-screened negative); Wegovy injection + liraglutide MASH F2–F3 (liraglutide pathway created August 2024 — one year before FDA approved Wegovy for MASH in August 2025; Wegovy MASH criteria formalized February 5, 2026 P&T meeting, implementing March 1, 2026); Zepbound for moderate-to-severe OSA (BMI ≥ 30, AHI ≥ 15, PAP-failed). Foundayo (orforglipron) on Weight Management Drugs PDL with Pharmacy PA but no defined PA criteria — first state in 29-state series. No third-party PBM — OHA Pharmacy Services direct FFS; DURM at Oregon State University College of Pharmacy provides clinical/DUR. Oregon Pharmacy Call Center 888-202-2126. Trillium verbatim: “Use of medications for the treatment of weight loss in adults (age ≥ 21 years of age) is a benefit exclusion under the Oregon Health Plan.”. With OR, the series reaches 29 articles + 29 distinct documented coverage patterns — 58% of the 50-state series. And Connecticut Medicaid HUSKY Health (DSS / Gainwell-claims / Prime-PDL / Acentra-RetroDUR / FFS-only since 2012) — Pattern #30: the partial-reversal triple-carve-out state with the largest statute-vs-operational-implementation gap in the series. Public Act 23-171 (Senator Matt Lesser, 2023) mandated HUSKY coverage of FDA-approved weight-loss drugs at BMI > 40 (or > 35 with comorbidities). DSS delivered orlistat + phentermine only (SPA 25-0014, ∼5.5% of the $85M FY2024 GLP-1 spend). Serial termination: January 15 → June 14 → August 1, 2025. Three active FDA-label carve-outs: Wegovy MACE (HUSKY A/B/C/D, eff. Feb 3, 2025); Zepbound OSA (HUSKY A/B/C/D, eff. July 1, 2025); Wegovy MASH (HUSKY A/C/D only — NOT HUSKY B; eff. Nov 3, 2025 — only CHIP exclusion in 30-state series). FFS-only state with no MCOs since 2012. Gainwell PA fax 1-866-759-4110. OLCRAH fair hearings within 60 days.. With CT, the series reaches 30 articles + 30 distinct documented coverage patterns — 60% of the 50-state series. And Iowa Medicaid (Iowa Health Link / IHAWP / Optum PBM) — Pattern #32: the dual-authority regulatory-exclusion state with a unified Incretin-Mimetics-for-Non-Diabetes-Indications PA pathway (three carve-outs, one form). Iowa is the only state in the 31-state taxonomy whose Wegovy and Zepbound PDL entries are simultaneously Preferred AND carry comment code “12” = “PA Required. Weight loss indication not covered” — the most operationally explicit PDL-line-item weight-loss-exclusion signal in the series. One form (470-0058, fax 1-800-574-2515) covers Wegovy MACE (age ≥ 18 — more permissive than Oklahoma’s ≥ 45; broader CVD list; no A1C requirement), Zepbound OSA (BMI ≥ 30, AHI ≥ 15), and Wegovy noncirrhotic MASH (F2/F3 fibrosis, adopted ∼5 months after August 2025 FDA approval). PBM = Optum (UHG subsidiary — UHC exited as MCO 2019 but Optum retained the state PBM contract; cleanest MCO-vs-PBM role separation in the series). Iowa Health Link’s three MCOs (Iowa Total Care/Centene, Wellpoint Iowa/Anthem, Molina) all defer to the state PDL. Iowa Health and Wellness Plan (IHAWP, Section 1115 demo #11-W-00289, launched January 1, 2014) has full structural parity with FFS Medicaid — same PDL, same PA criteria, same Optum-administered PBM. SF 552 / HF 701 (review-and-report only, “Referred to Health and Human Services” June 16, 2025, no voting record) is a study mandate, not a coverage mandate. KFF January 2026: not a covering state. IAC 441-78.2(4)(b)(2) unamended.. With IA, NV, and NM, the series reaches 33 articles + 33 distinct documented coverage patterns — 66% of the 50-state series. Nevada (Pattern #32) is the most restrictive Wegovy-CV-only carve-out state with sole Wegovy MACE (Web Announcement 3337) over a categorical “Agents used for weight loss” exclusion; layered three concurrent transitions (DHCFP→Nevada Health Authority July 1, 2025, MCO expansion Jan 1, 2026, Single PDL Jan 1, 2026); SB 244 (2025) died in money committee June 3, 2025 after DHCFP projected $165.4M biennium cost. New Mexico (Pattern #33) is the structurally unique legacy-AOM carve-in + modern-GLP-1 exclusion state: NMAC 8.324.4.14(A)(8) categorically excludes weight-loss drugs, but HCA operationally covers six older AOMs (Didrex, Fastin, Meridia [withdrawn 2010, still listed], Sanorex, Tenuate, Xenical) with PA at BMI > 40 or > 35+comorbidity, while explicitly excluding Imcivree/Saxenda/Wegovy/Zepbound — KFF lists NM as covering, a YMYL trap. HSD→HCA consolidation July 1, 2024 (SB 16/2023, Sec. Kari Armijo); four MCOs each with own PBM (BCBSNM/Prime, Presbyterian/Capital Rx, Molina/CVS, UHC/Optum) plus FFS Conduent; one of five states with no statewide PDL (Prime procured 2025 to implement statewide PDL in 2026); SB 193 (2025) died Jan 29, 2025 and amended only commercial statutes, not Medicaid. Arkansas (Pattern #34) is the three-program-bifurcated southern expansion state with the cleanest affirmative 2025 legislative ratification of a GLP-1 exclusion in the series: HB 1332 (GLP-1 mandate) died in Senate committee May 5, 2025; ACT 628 § 20-77-154(c) enacted January 1, 2026 explicitly excludes “injectable drugs to lower glucose levels or any other drugs prescribed for weight loss.” Three-way bifurcation: FFS / PASSE (state PDL, DUR Board PA) vs ARHOME expansion (~240–280K, QHP Metallic Drug List, outside state PDL). Three separate DUR-Board-approved standalone PA documents: Wegovy CV (July 17, 2024 — 3 months earlier than Oklahoma); Zepbound OSA (April 16, 2025 — includes active-suicidality denial criterion, unique in the series); Wegovy MASH (October 15, 2025). State Plan Attachment 3.1-A Page 5a (SPA 21-0009) carves IN androgens for weight gain but NOT anti-obesity drugs — the only state in the series with this inverse-carve-in asymmetry. DUR Board recurring sentence verbatim: “Arkansas Medicaid does not currently cover medications solely for the use of weight loss.” PBM = Prime Therapeutics State Government Solutions (Magellan Rx legacy; 1-800-424-7895); CoverMyMeds ePA effective August 1, 2025. PASSE (BH/SUD/DD, ~50K: CareSource PASSE, Empower, Summit Community Care) follows state PDL. Adult obesity ~37.4% (CDC BRFSS 2024).. With AR, the series reaches 34 articles + 34 distinct documented coverage patterns — 68% of the 50-state series. Mississippi (Pattern #35) is the only non-expansion southern state in the 35-state taxonomy with affirmative chronic-weight-management Medicaid GLP-1 coverage. Coverage began in 2023 under SPA 23-0013 (effective July 1, 2023), carving back the Miss. Admin. Code Title 23 Part 214 Rule 1.3.B.1 categorical exclusion of “Drugs when used for anorexia, weight loss, or weight gain.” Wegovy and Saxenda Preferred on the Universal PDL Antiobesity Select Agents class for ages 12 and older with manual PA (the only state in the series with operationalized pediatric chronic-weight-management coverage via CDC growth-chart BMI-percentile criteria embedded in the PA form); Xenical/orlistat Non-Preferred ages 12+. Zepbound NOT enumerated on the PDL (presumptive non-coverage). Wegovy in MASH PA Criteria Version 1 effective October 30, 2025 covers noncirrhotic F2–F3 fibrosis adults via separate PA Criteria document (gastroenterologist/hepatologist required, dose ≤ 2.4 mg/wk). Contrave and Qsymia categorically non-covered with verbatim DOM rationale “This agent is not rebated through CMS” (unique in the series — anchored to federal CMS rebate agreement requirement at Rule 1.3.B.17). Phentermine and Evekeo/amphetamine non-covered with clinical-evidence rationale. Pharmacy benefit architecture: Gainwell Technologies single statewide PBA effective July 1, 2024 serves FFS + MSCAN + MSCHIP uniformly (replaced Conduent + CCO-split architecture); BIN 025151, PCN DRMSPROD; MESA Provider Portal preferred. Three CCOs (Magnolia/Centene, Molina, TrueCare) under Aug 12, 2024 – Aug 11, 2028 contract — TrueCare replaced UHC in the June 2024 procurement. Per KFF Health News (October 15, 2025): just 2% of adults meeting weight criteria received a GLP-1 by December 2024; about 2,900 enrollees age 12 or older started treatment in the first 15 months with $12M DOM spend providing the drugs to 2,200 adult members. MS predates Tennessee (Pattern #13) by approximately two years as the earliest-adopting non-expansion southern state for chronic-weight-management Medicaid GLP-1 coverage. With MS, the series reaches 35 articles + 35 distinct documented coverage patterns — 70% of the 50-state series. West Virginia (Pattern #36) is the third state in the 36-state series to use a state university school of pharmacy for PA processing (alongside Oklahoma's OU College of Pharmacy / PMC and Arkansas's ULM College of Pharmacy / Prime Therapeutics). The WV BMS Office of Pharmacy Services PA criteria documents state verbatim that “Agents used for the purpose of weight loss are typically a benefit exclusion”; the Zepbound PA document adds that they are “not covered by West Virginia Medicaid.” Three FDA-label-restricted carve-outs are operationalized through the WVU Rational Drug Therapy Program (RDTP): (1) Wegovy CV (effective January 1, 2026) for secondary cardiovascular prevention — BMI ≥ 27, established CVD (prior MI, prior stroke, or symptomatic PAD with ABI ≤ 0.85 / revascularization / atherosclerotic amputation), cardiology/vascular/neurology consult, HbA1c ≤ 6.5% (uniquely-in-series excludes T2D patients from the CV pathway), 90-day initial PA; (2) Wegovy MASH in the same PA criteria document — noncirrhotic F2–F3 fibrosis confirmed by liver biopsy with NAFLD activity score ≥ 4 OR FibroScan/MRE, gastroenterology/hepatology consult, 90-day initial / 1-year reauth with documented no F4 progression and clinical response; (3) Zepbound OSA (effective July 1, 2025) — moderate-to-severe OSA with AHI ≥ 15 on sleep study within past 12 months, BMI ≥ 30 within past 3 months, CPAP counseling (not failure — more permissive than AR/OK), T2D patients first fail preferred T2D GLP-1 compliantly for three months (uniquely-in-series step-therapy bridge), 150-day initial / 6-month reauth with 10 mg maintenance tolerance and ≥ 5% weight loss. PBM: Gainwell Technologies(Provider Help Desk 1-888-483-0801; Member Help Desk 1-888-483-0797; BIN/PCN per WV Medicaid POS). PA processor: WVU RDTP (phone 1-800-847-3859 / fax 1-800-531-7787). BMS Office of Pharmacy Services: 304-558-1700. WV expanded Medicaid under the ACA effective January 1, 2014 with ~520K enrollees as of 2026 — structurally distinct from the non-expansion southern non-coverage cluster (TX, FL, GA, AL, KS, SC, TN-prior, MS for chronic-weight-management posture, WY). PDL revised May 14, 2026. With WV, the series reaches 36 articles + 36 distinct documented coverage patterns — 72% of the 50-state series. Utah (Pattern #37) is the only state in the 37-state series with a legislative pilot-program sunset date explicitly attached to chronic-weight-management coverage. The Utah Medicaid Pharmacy PA form — last updated January 1, 2026 — requires three separate prescriber attestations stating verbatim: “Coverage for weight management is part of a legislative pilot program and may not continue past 6/30/2026.” Three indication-permanent carve-outs continue indefinitely: Wegovy MACE (BMI ≥ 27, established CVD, concurrent guideline-recommended secondary prevention; 6-mo / 12-mo reauth); Zepbound OSA (in-lab attended PSG, 70% PAP adherence required — strictest in series; sleep medicine specialist consult; 12-mo); Wegovy MASH (dual-modality FIB-4 + biopsy/VCTE/ELF/MRE — unique in series; GI/hepatology consult). Utah is the only state with a UNIFIED 11-PART PA FORM covering Saxenda + Wegovy + Zepbound across all 6 indications. PA fax: 855-828-4992. UT expanded Medicaid January 1, 2020 via Prop 3. Coverage post-June 30, 2026 depends on Utah legislative action to extend, modify, or terminate the pilot. With UT, the series reaches 37 articles + 37 distinct documented coverage patterns — 74% of the 50-state series. Nebraska (Pattern #38) is structurally distinctive on TWO restrictive gates no other state imposes. Nebraska Medicaid (Heritage Health) does NOT cover GLP-1s for chronic weight management; three FDA-label carve-outs via bifurcated PA forms: Wegovy MACE for ages 45–74 only (narrowest age window in series, mirrors SELECT trial enrollment age range per PMID 37952131); Wegovy MASH requires a 6-month medically-supervised weight-loss-program completion BEFORE PA approval (most restrictive MASH gate in series — WV/AR/UT/OK have no parallel prerequisite); Zepbound OSA requires AHI/RDI/REI ≥ 15 + BMI ≥ 30 + 70% PAP adherence for 2+ months + sleep specialist consult. LB907 (Sen. Merv Riepe's 2024 coverage-mandate bill) was INDEFINITELY POSTPONED on April 18, 2024 after the Nebraska DHHS fiscal note projected $42.4M in annual cost; no successor bill identified as of May 15, 2026. PBM: Magellan Rx (rebranded Prime Therapeutics State Government Solutions 2024–2025; 1-866-244-8554 provider). Three Heritage Health MCOs (Nebraska Total Care/Centene, UHC, Molina — replaced Healthy Blue Jan 1, 2024) all follow the state Single PDL. NE expanded Medicaid effective October 1, 2020 via Initiative 427 (~90K expansion enrollees out of ~430K total). Maine (Pattern #39) adds a third FFS-dominant peer to the WV/AR/OK/UT/NE cluster but with one headline distinctive feature: NO Wegovy MASH carve-out. MaineCare does NOT cover GLP-1s for chronic weight management per 10-144 C.M.R. ch. 101, Ch. II, § 80.06(A) (“Anorexic, or certain weight loss drugs”) plus the verbatim January 1, 2026 PDL Weight Loss statement: “Weight loss drugs are not covered as permitted by Federal Medicaid regulations and Maine Medicaid (MaineCare) Policy.” Two narrow FDA-label-restricted carve-outs operate at the PDL coding level via PA Form #20420: Wegovy MACE under the CARDIAC RISK REDUCTION category — BMI strictly > 27 (narrowest BMI threshold language in the 39-state series), established CVD (MI / stroke / symptomatic peripheral arterial disease), patient NOT having diabetes / ESRD-dialysis / HFrEF (EF < 45%), not for weight loss only; and Zepbound OSA — BMI ≥ 30, AHI ≥ 15 on sleep study within 3 years (longer window than NE's 24 months / OK's 12 months), CPAP ineffective (AHI > 5 during therapeutic section) OR intolerant for 90 days, 3-month lifestyle modification attempt with failure to achieve weight loss, AND verbatim “Not for patients with T1DM, T2DM” (DUAL diabetes exclusion — most state OSA carve-outs only exclude T1DM). UNLIKE WV Pattern #36, AR Pattern #34, OK Pattern #24, UT Pattern #37, NE Pattern #38, MaineCare's GI/NASH PDL category covers ONLY Rezdiffra (resmetirol) — NO Wegovy MASH carve-out exists post-August-2025 FDA label expansion. LD 480 / HP 309 (Rep. Anne Graham (D-North Yarmouth), introduced February 11, 2025) was reported Ought-Not-To-Pass Pursuant To Joint Rule 310 on March 20, 2025 with a ~$42M FY26 / ~$53M FY27 fiscal note — parallel fiscal-pressure dynamic to NE's LB907 ($42.4M Indefinitely Postponed April 18, 2024). PBM: Change Healthcare Optum (Optum Rx) — provider PA 1-888-420-9711 / 1-888-445-0497 / MaineHD@optum.com; member helpdesk 1-866-796-2463. Maine is FFS-dominant — no full-risk Medicaid MCOs operate in the state (PCCM / PCMH / health-home programs supplement FFS for care coordination only). Maine expanded Medicaid effective January 10, 2019 via Question 2 of the 2017 ballot initiative — making Maine the first state to expand Medicaid through a ballot initiative process. Total MaineCare enrollment is approximately 410,000 (one of the highest Medicaid penetration rates by share of state population in the United States). With ME, the series reaches 39 articles + 39 distinct documented coverage patterns — 78% of the 50-state series.