Michigan Medicaid GLP-1 Coverage (2026): Pattern #10 — Partial Retainment With Morbid-Obesity Gate (BMI ≥ 40) + Bariatric-Surgery-Avoidance Prescriber Attestation + Appropriations-Statute Authority

Michigan Medicaid — administered by the Michigan Department of Health and Human Services (MDHHS) for approximately 2.5–2.7 million enrollees — is a partial-retainment state: it retained GLP-1 coverage for chronic weight management on January 1, 2026, but only for patients classified as morbidly obese (BMI ≥ 40 kg/m²) who have failed every preferred non-GLP-1 anti-obesity medication and whose prescriber attests in writing that the GLP-1 is being used “only as a measure to avert the need for higher-cost bariatric surgery.” This bariatric-surgery-avoidance prescriber attestation is uniquely Michigan in the 10-state cluster and is the load-bearing structural barrier that distinguishes Pattern #10 from every other state. Michigan is NOT among the four states KFF (January 2026) classifies as having “eliminated coverage” (California, New Hampshire, Pennsylvania, and South Carolina), but the morbid-obesity gate is narrow enough that the practical impact on the roughly 90,000 Michigan Medicaid GLP-1 users documented in FY 2024 is severe for those whose coverage was based solely on the prior BMI ≥ 30 (or BMI ≥ 27 + comorbidity) threshold.

TL;DR — What Michigan Medicaid covers in 2026

The January 1, 2026 architecture, established by MDHHS Numbered Letter L 25-73 (December 8, 2025) under the authority of Public Act 22 of 2025 (HB 4706), divides Michigan Medicaid GLP-1 coverage into five distinct pathways:

• Chronic weight management (morbid obesity only): Wegovy, Wegovy HD 7.2 mg, Saxenda/liraglutide, and Zepbound are covered at BMI ≥ 40 with 5-class step therapy + bariatric-surgery-avoidance prescriber attestation. Adults 18+ for all four agents; adolescents 12–17 for Wegovy and Saxenda only. 6-month authorization cycles.
• Type 2 diabetes: Ozempic, Trulicity, Victoza, Rybelsus, Mounjaro, Byetta, Bydureon BCise, Soliqua, Xultophy — all covered with PA. Coverage UNAFFECTED by L 25-73. 1-year authorization cycles.
• Cardiovascular risk reduction (Wegovy): BMI ≥ 27 + established CVD (prior MI, prior stroke, or peripheral arterial disease). 6-month cycles. No diabetes exclusion. No specialist consultation required.
• MASH (Wegovy): BMI ≥ 27 + noncirrhotic MASH with F2/F3 fibrosis. 6-month cycles. No FIB-4 thresholds, no imaging/biomarker requirements, no alcohol-use exclusion — the simplest MASH pathway in the 10-state cluster.
• Obstructive sleep apnea (Zepbound): BMI ≥ 27 + moderate-to-severe OSA. 6-month cycles. No PAP trial-and-fail requirement. BMI ≥ 27 is the broadest BMI floor for any FDA-approved GLP-1 indication among the 8+ verified states.

The article must not be read as a positive-coverage anchor. Michigan retained the door but moved the lock. The pre-2026 baseline (BMI ≥ 30, or BMI ≥ 27 with comorbidity) matched FDA-label chronic-weight-management criteria; the post-2026 gate (BMI ≥ 40 + bariatric-surgery-avoidance attestation + 5-class step therapy) is the most restrictive chronic-weight-management path in the 10-state cluster.

Pattern #10 in the 50-state taxonomy: PARTIAL RETAINMENT WITH MORBID-OBESITY GATE

The 50-state Medicaid GLP-1 series assigns each state a structural pattern based on how the coverage architecture is established and what patients can practically access. Michigan is Pattern #10 — PARTIAL RETAINMENT WITH MORBID-OBESITY GATE, distinct from every prior state in the cluster:

Michigan is the first state in this series to retain a chronic-weight-management GLP-1 pathway while raising the BMI floor by ten points (from 30 to 40) and adding the bariatric-surgery-avoidance attestation. Its authority structure is also uniquely distinct: where Ohio (OAC 5160-9-03), New York (18 NYCRR § 505.3(g)(3)), Illinois (89 Ill. Adm. Code § 140.441(b)), and Pennsylvania (55 Pa. Code § 1121.54) all anchor their rules in state Administrative Code regulations, Michigan’s gate is mandated entirely by appropriations statute — Public Act 22 of 2025 — rather than a state administrative rule. This structural distinction matters clinically and legally: the gate could, in principle, be un-mandated by a future appropriations act without requiring the standard rule-making process that amending an Administrative Code regulation would demand.

The load-bearing barrier: the bariatric-surgery-avoidance prescriber attestation

No other verified state in the 10-state cluster uses the following language. It is verbatim from the Prime Therapeutics Michigan Medicaid Clinical and PDL Criteria, version 05012026v1, pages 253–255, Anti-Obesity/Weight Loss Agents (Non-Preferred GLP1s Only), Initial Request criteria:

“Prescriber attests that use of this GLP1 agent for weight loss is considered only as a measure to avert the need for higher-cost bariatric surgery”

The same language appears in MDHHS Letter L 25-73 (December 8, 2025):

“Coverage must be considered only as a measure to avert the need for higher-cost bariatric surgery.”

This attestation is not a clinical guideline recommending bariatric surgery as a prerequisite. The MDHHS criteria position bariatric surgery as the escalation alternative that the GLP-1 must be justifying deferral of — not as a prior step the patient must have attempted. The practical clinical consequence is that the prescriber must certify on the PA request, in writing, that their patient's GLP-1 prescription is the treatment being used specifically to avoid the patient needing bariatric surgery. A prescriber treating a patient at BMI 38 or at BMI 41 who does not regard bariatric surgery as a realistic clinical option for the patient may have difficulty signing this attestation in good faith, because the attestation requires the prescriber to treat bariatric surgery as a clinically plausible alternative that the GLP-1 is deferring.

Michigan’s verifier brief, compiled May 10, 2026, identified no other state in the 50-state Medicaid GLP-1 series that uses this specific bariatric-surgery-avoidance attestation language. New York’s NYRx Wegovy DUR pathway at BMI ≥ 40 has no bariatric-surgery clause. Pennsylvania’s MAB2025112403 has no five-class step-therapy ladder and no bariatric-surgery-avoidance framing. The attestation is Michigan-specific and uniquely defines Pattern #10.

BMI ≥ 40 morbid-obesity floor: a 10-point raise from the prior threshold

The verbatim PA criterion from Prime Therapeutics Clinical Criteria v 05012026v1, page 254:

“Prescriber attests patient age ≥18 years and has an initial body mass index (BMI) classified as morbidly obese (e.g., baseline BMI ≥ 40 kg/m2 or greater)”

Before January 1, 2026, Michigan Medicaid's coverage threshold — established by MDHHS Policy Bulletin MSA 21-49 effective February 1, 2022 — was structured around the standard chronic-weight-management thresholds consistent with FDA Wegovy and Saxenda labels: BMI ≥ 30 for adults, or BMI ≥ 27 with at least one weight-related comorbidity (diabetes, sleep apnea, hypertension, or dyslipidemia). The January 1, 2026 change raised the adult chronic-weight-management floor by 10 BMI points and dropped the comorbidity pathway entirely for the GLP-1 class.

This means patients at BMI 30–39.9 — the population meeting FDA label criteria for Wegovy and Saxenda, and meeting the prior Michigan Medicaid criteria — are now excluded from the chronic-weight-management GLP-1 pathway. A patient at BMI 35 with type 2 diabetes still qualifies for Ozempic or Mounjaro via the T2D pathway, but does not qualify for Wegovy or Saxenda under the weight-management pathway unless they also have established CVD (MACE pathway) or noncirrhotic MASH (MASH pathway).

For adolescents age 12–17, the criterion is prescriber attestation of morbid obesity per CDC growth charts for age and sex, without specifying a numeric BMI percentile cutoff:

“Prescriber attests patient age ≥12 years to <18 years and has an initial BMI per CDC growth charts for age and sex and is classified as morbidly obese”

5-class step therapy: the broadest anti-obesity-drug ladder in the 10-state cluster

Before a morbidly obese Michigan Medicaid patient can access Wegovy, Wegovy HD, Saxenda/liraglutide, or Zepbound under the weight-management pathway, the PA criteria require one of four conditions to be true. Verbatim from Prime Therapeutics Clinical Criteria v 05012026v1, pages 253–254:

“CRITERIA TO APPROVE
• Allergy to all five types of preferred medications (e.g., at least 1 of each benzphetamine, diethylpropion, orlistat products, phendimetrazine, and phentermine products); OR
• Contraindication or drug to drug interaction with all five types of preferred medications; OR
• History of unacceptable side effects of all five types of preferred medications; OR
• Trial and failure with all five types of preferred agents (e.g., at least one orlistat agent and one phentermine product in addition to benzphetamine, diethylpropion and phendimetrazine)”

The five classes are: benzphetamine, diethylpropion, orlistat, phendimetrazine, and phentermine products. The prescriber must document trial and failure of (or allergy/contraindication/DDI/side-effects to) at least one agent from each of these five classes before a GLP-1 weight-management PA will be considered.

This is the broadest anti-obesity step-therapy ladder in the 10-state cluster. Pennsylvania’s MAB2025112403 has no comparable 5-class ladder for the residual obesity pathway. New York’s NYRx Wegovy DUR pathway imposes a lifetime two-attempt limit but does not require trial-and-failure of phentermine, orlistat, benzphetamine, or the other classes. No other verified state in the cluster imposes trial-and-failure of all five non-GLP-1 anti-obesity agent classes as a precondition for GLP-1 coverage.

The preferred non-GLP-1 pathway also has its own PA criteria, at a lower BMI floor (BMI ≥ 30 or BMI ≥ 27 + comorbidity), covering orlistat (Xenical), phentermine, phentermine-topiramate (Qsymia), benzphetamine, diethylpropion, and phendimetrazine. These agents remain accessible to patients at BMI ≥ 30 who do not meet the morbid-obesity threshold for GLP-1 coverage.

Triple-anchor: federal statute, appropriations statute, and operational notice

Federal authority — 42 U.S.C. § 1396r-8(d)(2)(A)

Michigan’s morbid-obesity gate rests on the same federal permissive authority as Texas, Ohio, Illinois, New York, and Pennsylvania. Verbatim:

“The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.”

Michigan has chosen to restrict rather thanexclude under (d)(2)(A) — the statute permits either posture. The restriction is operative as a BMI threshold and a prescriber-attestation requirement, not a categorical ban.

State legislative authority — Public Act 22 of 2025 (HB 4706, signed October 7, 2025)

The Michigan Legislature enacted House Bill 4706 of 2025 as Public Act 22 of 2025, the FY 2025-2026 omnibus appropriations act. Governor Gretchen Whitmer signed the bill on October 7, 2025, effective immediately. The bill was sponsored by Rep. Ann Bollin (R-District 49). Per the legislature.mi.gov bill page, the short title reads:

“Appropriations: omnibus; appropriations for multiple departments and branches for the fiscal year 2025-2026 and supplemental appropriations for fiscal year 2024-2025”

MDHHS Letter L 25-73 identifies Public Act 22 of 2025 as the operative legislative authority:

“Recent enactment of Public Act 22 of 2025 (Fiscal Year 2026 Budget legislation) has updated how Medicaid will approve coverage of anti-obesity medications.”

Critical structural point: Michigan’s authority is an appropriations statute, not an administrative rule. This is structurally distinct from every other state in the cluster that has a standing administrative-code anchor. The verifier brief, after an exhaustive search of the Michigan Compiled Laws and Administrative Rules Chapter 400, found no standing MCL section or Administrative Code rule independently of Public Act 22 of 2025 that would restrict GLP-1 obesity coverage. This means the gate is mandate-dependent on the annual appropriations cycle: a future legislature could remove the boilerplate from the following year’s omnibus budget without a formal rule-making proceeding. As of May 10, 2026, no Michigan 2025-2026 legislative bill to restore broader GLP-1 obesity coverage has been identified.

The fiscal trigger, per Bridge Michigan reporting (October 2025):

“Under the $81 billion state budget, which reduced funding for the Michigan Department of Health and Human Services by 20%, pharmaceutical appropriations for GLP-1 drugs were reduced by $240 million.”

Operational notice — MDHHS Letter L 25-73 (December 8, 2025)

The canonical Michigan Medicaid primary source for providers and pharmacies is MDHHS Numbered Letter L 25-73, “Update of Pharmacy Drug Coverage for Treatment of Obesity,” signed by Meghan E. Groen, Chief Deputy Director, Health Services. Full verbatim operational text, as distributed:

“MDHHS Medicaid policy bulletin MSA 21-49, effective February 1, 2022, established Medicaid pharmacy drug coverage of products exclusively for the treatment of obesity only in accordance with approved prior authorization (PA) requirements. Recent enactment of Public Act 22 of 2025 (Fiscal Year 2026 Budget legislation) has updated how Medicaid will approve coverage of anti-obesity medications.

The purpose of this letter is to update and clarify Medicaid pharmacy benefit drug coverage for the treatment of obesity only with Glucagon-like peptide-1 (GLP-1) receptor agonist medications. Some examples of these medications include:
• Liraglutide (generic for Saxenda)
• Saxenda
• Wegovy
• Zepbound

Effective for Dates of Service On or After January 1, 2026:
• Coverage of GLP-1 medications when prescribed solely to treat obesity, including requests for continuation, will be reduced.
• Coverage of GLP-1 medications when requested for other existing indications other than to treat obesity will not be changing.
• GLP-1 product coverage requested for treatment of obesity will require additional clinical PA requirements such as the following:
o Patient must be classified as morbidly obese; and
o Coverage is contingent on documented failure of all other clinically appropriate weight-loss interventions (including a trial and failure of Preferred Drug List [PDL] preferred anti-obesity agents); and
o Coverage must be considered only as a measure to avert the need for higher-cost bariatric surgery.

Some of these medications (i.e., Saxenda and Wegovy) will become non-preferred on the Single Preferred Drug List (Single PDL) in new PDL classes for their other covered indications. Non-preferred products have a $3 copayment responsibility instead of $1 for program beneficiaries who are not exempt from a copayment or not enrolled in a Medicaid Health Plan.

PAs for individuals that were approved for these GLP-1 medications before January 1, 2026 will be honored for the remaining six months authorized. This will prevent unnecessary extra medical appointments for medication changes and avoid potential transportation issues or other unanticipated impacts to program beneficiaries, prescribers, and pharmacies.”

Source: MDHHS Numbered Letter L 25-73, December 8, 2025, Meghan E. Groen, Chief Deputy Director, Health Services.

Wegovy cardiovascular risk reduction pathway — broader than PA, no diabetes exclusion

Michigan Medicaid covers Wegovy (semaglutide) for cardiovascular risk reduction with prior authorization under a separate PDL class. The full verbatim Initial Request criteria from Prime Therapeutics Clinical Criteria v 05012026v1, pages 256–257:

“MISCELLANEOUS: GLP1S FOR CARDIOVASCULAR RISK REDUCTION - WEGOVY (SEMAGLUTIDE)

Length of Authorization: Initial = 6 months; Renewal = 6 months

INITIAL REQUEST
• Prescriber attests that the patient will not use Wegovy concurrently with another GLP-1 agonist; AND
• Prescriber attests that the patient will not use Wegovy concurrently with a non-GLP1 weight loss medication; AND
• Prescriber attests that the patient will not use Wegovy concurrently with a medication that contains a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin or sitagliptin); AND
• Patient ≥ 18 years of age; AND
• Prescriber attests patient has an initial body mass index [BMI] ≥ than 27 kg/m2; AND
• Prescriber attests patient has established cardiovascular disease (e.g., Wegovy is being prescribed for cardiovascular risk reduction in patients with prior myocardial infarction, prior stroke or peripheral arterial disease)”

Michigan’s MACE pathway is notable for what it omits compared to other states:

• No diabetes exclusion — a patient with T2D plus established CVD plus BMI ≥ 27 can use the MACE pathway. Ohio requires A1C < 6.5% and explicitly excludes T1D/T2D from its Metabolic Modifiers MACE criteria. Michigan does not.
• No specialist consultation requirement — Pennsylvania requires cardiology or vascular surgery involvement for MACE approvals; Michigan defers to the prescribing physician.
• No lifetime attempt cap — New York’s NYRx Wegovy DUR pathway caps at two lifetime treatment attempts. Michigan has no cap; renewals are 6-month cycles as long as criteria are met.

One important caveat: the renewal criterion requires the patient to have “maintained a weight loss of ≥ 5% from baseline weight at initiation of therapy.” The FDA SELECT trial’s primary endpoint was MACE reduction (~20% relative risk reduction at 2 years) rather than weight loss, and not all patients achieving MACE benefit in SELECT reached 5% weight loss. Michigan’s 5%-weight-loss renewal threshold could deny renewal to a patient who is deriving documented cardiovascular benefit from Wegovy but has not reached the weight threshold.

Wegovy MASH pathway — the simplest in the 10-state cluster

Michigan Medicaid covers Wegovy for noncirrhotic MASH with F2/F3 liver fibrosis. This is the FDA-label indication approved August 15, 2025. The full verbatim Initial Request criteria from Prime Therapeutics Clinical Criteria v 05012026v1, pages 258–260:

“MISCELLANEOUS: GLP1S FOR METABOLIC DYSFUNCTION ASSOCIATED STEATOHEPATITIS (MASH) – WEGOVY (SEMAGLUTIDE)

Length of Authorization: Initial = 6 months; Renewal = 6 months

INITIAL REQUEST
• Prescriber attests that the patient will not use Wegovy concurrently with another GLP-1 agonist; AND
• Prescriber attests that the patient will not use Wegovy concurrently with a non-GLP1 weight loss medication; AND
• Prescriber attests that the patient will not use Wegovy concurrently with a medication that contains a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin or sitagliptin); AND
• Patient ≥ 18 years of age; AND
• Prescriber attests patient has an initial body mass index [BMI] ≥ than 27 kg/m2; AND
• Prescriber attests patient has 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)”

Michigan’s MASH pathway is the simplest in the 10-state cluster because it lacks every layer of biomarker documentation that other states impose:

• No FIB-4 thresholds — Pennsylvania’s MAB2025112403 requires age-stratified FIB-4 scores (≥ 1.3 or ≥ 2.0 depending on age). Michigan does not.
• No imaging or biomarker confirmation requirements — Pennsylvania requires FibroScan, MRE, SWE, or ELF score documentation. Ohio’s Jan 7, 2026 P&T criteria require biopsy or dual imaging biomarkers. Michigan defers to the prescriber’s attestation of F2/F3 fibrosis.
• No alcohol-use exclusion — Pennsylvania has an explicit alcohol-use exclusion in the MASH pathway. Michigan does not.
• No Rezdiffra (resmetirom) sequencing requirement — Ohio requires the patient to not be on resmetirom concurrently. Michigan does not specify.
• No specialist consultation requirement — Pennsylvania and Ohio both require hepatologist or gastroenterologist involvement. Michigan defers to the prescribing physician.

The verifier brief cautions: Michigan’s brevity should not be read as clinically looser practice. MDHHS likely defers detailed clinical staging to the prescribing physician’s judgment per the FDA Wegovy MASH label. The MASH pathway is operative at BMI ≥ 27 — the same FDA-label floor — making it accessible to the same population the FDA study enrolled.

Zepbound OSA pathway — BMI ≥ 27, broadest floor in the 8-state verified set

Michigan covers Zepbound (tirzepatide) for moderate-to-severe obstructive sleep apnea with prior authorization. The full verbatim Initial Request criteria from Prime Therapeutics Clinical Criteria v 05012026v1, pages 260–262:

“MISCELLANEOUS: GLP1S FOR OBSTRUCTIVE SLEEP APNEA – ZEPBOUND (TIRZEPATIDE)

Length of Authorization: Initial = 6 months; Renewal = 6 months

INITIAL REQUEST
• Prescriber attests that the patient will not use Zepbound concurrently with another GLP-1 agonist; AND
• Prescriber attests that the patient will not use Zepbound concurrently with a non-GLP1 weight loss medication; AND
• Prescriber attests that the patient will not use Zepbound concurrently with a medication that contains a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin or sitagliptin); AND
• Patient ≥ 18 years of age; AND
• Prescriber attests patient has an initial body mass index [BMI] ≥ than 27 kg/m2; AND
• Patient has a documented diagnosis of moderate to severe obstructive sleep apnea (OSA)”

Key points on the Michigan OSA pathway:

• BMI ≥ 27 is the broadest floor in the verified 8-state set for any FDA-approved GLP-1 indication. The Zepbound OSA FDA label (SURMOUNT-OSA, approved August 2024) enrolled a study population with a mean BMI of 39; Michigan’s BMI ≥ 27 floor is broader than the FDA study population. Pennsylvania’s MAB2025112403 requires BMI ≥ 35 for OSA — narrower than Michigan and more conservative than the FDA population.
• No PAP trial-and-fail or PAP-adherence documentation required — Pennsylvania requires either documented PAP adherence (≥ 4 hours/night, 70% of nights, 30 days) or documented PAP intolerance with troubleshooting attempts. Michigan requires only a “documented diagnosis of moderate to severe OSA.”
• No step therapy through Ozempic/Wegovy/Mounjaro — Pennsylvania requires failure of Ozempic AND Wegovy AND Mounjaro before approving Zepbound for OSA. Michigan has no GLP-1 step-therapy requirement for the OSA pathway.

Type 2 diabetes pathway — unaffected by L 25-73, largest coverage cohort

The T2D pathway is the largest unaffected coverage area. MDHHS L 25-73 states explicitly: “Coverage of GLP-1 medications when requested for other existing indications other than to treat obesity will not be changing.” Per Bridge Michigan reporting citing MDHHS data, approximately 60% of Michigan Medicaid GLP-1 claims in FY 2024 were for diabetes treatment — roughly 54,000 of the 90,324 total users. That population’s coverage is unchanged.

The Michigan Medicaid PDL class “Diabetes: Incretin Mimetics and Combinations” includes the following GLP-1 agents with 1-year authorization cycles. Verbatim quantity limits from Prime Therapeutics Clinical Criteria v 05012026v1, page 144:

T2D GLP-1 PA criteria require “Diagnosis of type 2 diabetes” plus discontinuation of other GLP-1 agonists and DPP-4 inhibitors. The PA criteria for preferred agents and non-preferred agents differ only in that non-preferred agents additionally require allergy, contraindication, drug-drug interaction, or trial-and-failure of one preferred medication within the same subgroup.

Per-drug verified coverage status (May 2026 v1 PDL)

Coordinated multi-program retrenchment: Medicaid and State Health Plan both narrowed January 1, 2026

The GLP-1 weight-management restriction in Michigan Medicaid was not an isolated program decision. Per WebSearch-verified snippets from the 2026 State of Michigan Employee Benefits Open Enrollment documents, the Michigan Civil Service Commission also narrowed GLP-1 weight-management coverage in the State Health Plan (SHP) PPO and State HDHP effective January 1, 2026. Per the 2026 Open Enrollment (BOE26.pdf, verified via WebSearch snippet only):

“Effective January 1, 2026, GLP-1 inhibitors (e.g., Saxenda, Wegovy, and Zepbound) will no longer be covered under the SHP PPO and State HDHP for weight management and sleep apnea but will continue to be covered for diabetes management and cardiovascular diagnoses.”

And per the 2026 Retiree Benefits Bulletin (26RetDB.pdf, verified via WebSearch snippet only):

“beginning January 1, 2026, the SHP will no longer cover the category of drugs known as GLP-1 inhibitors for weight management except when required by Medicare.”

Important verification caveat: these SHP quotes are from WebSearch snippets; the BOE26.pdf and 26RetDB.pdf documents returned HTTP 403 on direct fetch by the verifier agent. Do not rely on the exact wording of these quotes in formal legal proceedings without re-verifying the primary documents.

The structural contrast between the SHP and Medicaid decisions is notable: the SHP decision is stricter than the Medicaid decision. The SHP plans entirely terminated weight-management AND OSA coverage, with no morbid-obesity carve-out. Michigan Medicaid retained the BMI ≥ 40 carve-out. The Medicaid decision was driven by Public Act 22 of 2025 and the $240 million pharmaceutical-appropriations reduction; the SHP decision was a Civil Service Commission actuarial decision operating on a separate timeline. Both took effect January 1, 2026. This coordination is factually documented by the coincident timing, not evidence of a formal joint decision. MDHHS spokesperson Lynn Sutfin confirmed the Medicaid direction per Michigan Public Radio (October 21, 2025): “to implement stricter criteria for GLP-1 medications prescribed solely for weight loss.”

Patient impact: ~90,324 FY 2024 users, ~18,000 most affected

Michigan Medicaid’s GLP-1 weight-management coverage growth before the January 2026 restriction was substantial. Per Bridge Michigan and Michigan Public Radio, citing MDHHS data:

“90,324 patients using GLP-1s in Michigan Medicaid in 2024” and “20,935 patients in fiscal year 2021.”

That fourfold growth over three years (FY 2021–FY 2024) represents the expansion of coverage following the February 2022 MSA 21-49 bulletin. The gross GLP-1 spend in FY 2024 was $409 million before manufacturer rebates (estimated net cost ~$80 million after approximately 80% typical Medicaid rebate).

The patient-impact arithmetic from the verifier brief:

• ~60% (≈ 54,000) of the 90,324 total users had diabetes as the primary indication — coverage unaffected by L 25-73.
• ~80% (≈ 72,000) had “other qualifying conditions beyond obesity” (T2D + MACE + MASH + OSA) — most of these retain coverage via non-obesity pathways.
• ~20% (≈ 18,000) without other qualifying conditions were likely using GLP-1s purely for weight management under the prior BMI ≥ 30 threshold — this is the population most directly affected by the morbid-obesity gate.

The University of Michigan IHPI / Medical School op-ed cited an estimate of “up to a million Michiganders with low incomes who are overweight or have obesity” as potentially affected. That figure refers to the eligible-population estimate under the prior BMI ≥ 30 criteria — patients whocould have qualified for coverage but may not have been receiving it. The verified actual-user figure is ~90,324 (FY 2024 MDHHS data). The article anchors patient impact on the verified number.

Professor A. Mark Fendrick, MD (U-M Medical School / IHPI), per the expert Q&A:

“from an economic perspective, the policy reducing coverage for GLP-1 medications will save the Michigan Medicaid program $240 million in 2026”

Professor Lauren D. Oshman, MD, MPH (U-M Medical School / IHPI):

“decreasing access to GLP-1 medications for Michigan Medicaid beneficiaries could worsen existing health disparities, because obesity and related chronic health conditions are more common among individuals with low socioeconomic status and those from racial and ethnic minority groups”

These quotes are from an academic expert Q&A and reflect the views of two University of Michigan clinician-researchers. They are not MDHHS policy statements.

PBM structure: Prime Therapeutics Management LLC (formerly Magellan Rx), plus nine managed-care plan PBMs

Michigan Medicaid fee-for-service (FFS) pharmacy is administered through Prime Therapeutics Management LLC, a Prime Therapeutics LLC subsidiary. The criteria document footer reads: “© 2010–2026 Prime Therapeutics Management LLC, a Prime Therapeutics LLC company.”

Critical correction: Some prior sources refer to Michigan Medicaid’s PBM as “Magellan Medicaid Administration.” This is no longer accurate as of 2026. Prime Therapeutics acquired Magellan Rx Management from Centene in 2022, and the Michigan Medicaid book of business now operates under the Prime Therapeutics brand.

Michigan’s MDHHS Common Formulary structure: MDHHS publishes the Single PDL and the Prime Therapeutics clinical criteria as the statewide floor. Each of the nine Medicaid Health Plans (MHPs) is bound by this floor — MHP formularies cannot bemore restrictive than the MDHHS Common Formulary, but can be less restrictive (i.e., may waive step therapy or lower BMI thresholds at their discretion with MDHHS approval). As of May 10, 2026, no MHP has publicly announced a waiver of the BMI ≥ 40 or 5-class step-therapy requirement.

Three MHPs confirmed their January 1, 2026 implementation via primary-source bulletins:

• Meridian Health Plan of Michigan (Centene/Wellcare) — December 16, 2025 provider bulletin confirms full deference to L 25-73 with verbatim “used only as a measure to avert the need for bariatric surgery” language. Existing PA transition: honored through remaining 6-month period; new criteria apply at first renewal.
• HAP CareSource — December 19, 2025 notification (MI-Multi-P-4890450) confirms implementation for both Medicaid and MI Coordinated Health HMO D-SNP enrollees.
• Priority Health Choice — December 15, 2025 provider bulletin confirms “coverage and criteria of GLP-1 weight-loss drugs Saxenda, Wegovy and Zepbound will become more restrictive for all Michigan Medicaid members” effective January 1, 2026.

Seven MHPs did not have individually verified bulletins in this brief: Aetna Better Health of Michigan, AmeriHealth Caritas Michigan, Blue Cross Complete of Michigan, Humana Healthy Horizons in Michigan, McLaren Health Plan, Molina Healthcare of Michigan, and UnitedHealthcare Community Plan. Per MDHHS Common Formulary structure, all nine MHPs are bound by the MDHHS Single PDL floor. Plan-specific questions should be directed to the MHP’s pharmacy department or to the MDHHS Common Formulary mailbox at MDHHSCommonFormulary@michigan.gov.

Populations affected and unaffected by the January 1, 2026 change

Affected populations

• Adults at BMI 27–39 using GLP-1s solely for weight management: the January 2026 gate terminates coverage at their current PA renewal. Existing approvals were honored for the remaining 6-month period from January 1, 2026.
• Existing PA holders (transition trap): the “1st renewal” provision requires the prescriber to retroactively attest that the patient was classified as “morbidly obese when they were initially started on the GLP1 agent for weight loss.” A patient initially approved under the prior BMI ≥ 30 criteria at BMI 34 cannot satisfy this retroactive attestation and will be denied at first renewal under the new criteria unless they have since progressed to BMI ≥ 40.
• State Health Plan members and retirees: the parallel SHP decision entirely terminated weight-management and OSA GLP-1 coverage, with no morbid-obesity carve-out. SHP is administered by the Michigan Civil Service Commission separately from MDHHS.

Unaffected or protected populations

• T2D patients: Ozempic, Trulicity, Victoza, Rybelsus, Mounjaro, Byetta, Bydureon BCise, Soliqua, Xultophy all retain their T2D pathway with 1-year authorization cycles.
• MACE patients (Wegovy, BMI ≥ 27 + established CVD): unaffected. No diabetes exclusion, no specialist requirement.
• MASH patients (Wegovy, BMI ≥ 27 + F2/F3 fibrosis): unaffected. Simplest pathway in the 10-state cluster.
• OSA patients (Zepbound, BMI ≥ 27 + moderate-to-severe OSA): unaffected by the Medicaid restriction. No PAP step required.
• Morbidly obese patients (BMI ≥ 40) who can satisfy 5-class step therapy and bariatric attestation: the narrow coverage pathway remains available. Adults 18+ for all four GLP-1 agents; adolescents 12–17 for Wegovy and Saxenda only.
• Adolescents under 21 under EPSDT: the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) mandate (42 U.S.C. § 1396a(a)(43) and § 1396d(r)) requires all medically necessary treatments for individuals under 21. A non-morbidly-obese adolescent denied the GLP-1 pathway may have a theoretical challenge via MOAHR if the prescriber documents medical necessity. EPSDT challenges to the morbid-obesity gate depend on individual MOAHR ALJ findings; no adjudication of this issue has been verified for this article.

10-state comparison: how Michigan fits the cluster

Michigan is the first state in the 10-state series to retain a chronic-weight-management pathway while restricting it to morbid obesity. Key comparative observations:

• vs. Pennsylvania (Pattern #7): PA terminated ALL GLP-1 chronic-weight-management coverage effective January 1, 2026. Michigan retained a BMI ≥ 40 pathway; PA did not. PA’s gate is regulation-based (55 Pa. Code § 1121.54 + MAB2025112403 + 55 Pa.B. 8828); Michigan’s gate is appropriations-statute-based (Public Act 22 of 2025). Michigan’s adolescent pathway is preserved (Wegovy + Saxenda at BMI ≥ 40); PA explicitly excluded Saxenda for all populations including adolescents.
• vs. New York (Pattern #3): NY’s morbid-obesity carve-out (NYRx Wegovy DUR pathway, BMI ≥ 40) is the most structurally similar prior-state architecture. NY’s authority is the longstanding 18 NYCRR § 505.3(g)(3) state regulation predating the GLP-1 era. Michigan’s authority is an appropriations statute enacted 2025. NY adds a lifetime two-attempt cap; Michigan has no cap. NY has no bariatric-surgery-avoidance attestation; Michigan’s is the load-bearing structural barrier.
• vs. Ohio (Pattern #6): Ohio’s Jan 7, 2026 Metabolic Modifiers class adds MACE and MASH pathways similar to Michigan’s. Both states have non-obesity-indication carve-backs. Ohio’s authority is OAC 5160-9-03(B)(1) plus Gainwell SPBM; Michigan’s is an appropriations statute. Ohio’s MACE pathway excludes T1D/T2D (A1C < 6.5%); Michigan does not. Ohio does not have a chronic-weight-management pathway at any BMI; Michigan retains one at BMI ≥ 40.
• vs. Illinois (Pattern #5): Both states impose the tightest effective gates in the cluster for weight management — IL via 89 IAC § 140.441(b) regulatory exclusion (no pathway at any BMI), Michigan via appropriations statute + morbid-obesity gate (narrow pathway at BMI ≥ 40). IL has no MASH, MACE, or OSA carve-back-in; Michigan has all three.
• vs. California (Pattern #2): CA terminated all GLP-1 obesity coverage January 1, 2026, then reinstated Wegovy for MASH only April 1, 2026. Michigan never fully terminated; it narrowed. Michigan’s MASH pathway is simpler (no FIB-4, no FibroScan) than CA’s reinstated pathway.

Patient action steps + Michigan MOAHR fair-hearing pathway

Step 1: Verify your indication pathway

Before assuming a denial is final, identify which of the five Michigan Medicaid GLP-1 pathways your prescriber is submitting under. T2D, MACE, MASH, and OSA pathways are substantially unaffected by the January 1, 2026 change. Many patients whose weight-management PA will be denied can still access Wegovy or Zepbound via a separate indication if they meet those criteria.

Step 2: MHP internal appeal (for managed-care enrollees)

If you are enrolled in one of the nine Medicaid Health Plans, your first step after a GLP-1 PA denial is the MHP’s internal appeal process — typically a 30–45 day process. The most viable internal-appeal arguments are:

• Prescriber documentation supports morbid obesity (BMI ≥ 40) but the MHP misclassified the BMI or misread the prescriber attestation.
• The denial applied incorrect criteria (e.g., applied the weight-management criteria to a MACE/MASH/OSA-indication request).
• Step-therapy documentation was submitted but the MHP clerk did not register it.

Step 3: MOAHR fair hearing (120-day window)

Per the MDHHS Medicaid Fair Hearings web page:

“You have a right to request a State Fair Hearing if you are a Medicaid recipient and one of the agencies issued an adverse benefit decision including denying or limiting the authorization of a requested service, reducing, suspending, or terminating a previously authorized service, or denying the payment for a service.”

“You must request a State Fair Hearing within 120 calendar days from the date of the notice of resolution of the local appeal decision.”

“A request for a State Fair Hearing must be in writing and it is recommended that you use the State approved form (MDHHS-5617-MAHS) for requesting a hearing.”

Per MOAHR:

“MOAHR was created by Executive Order 2019-06 as a Type 1 Agency within the Department of Licensing and Regulatory Affairs (LARA) and holds administrative hearings for a variety of departments when decisions are contested.”

Practical timeline:

• Day 0: PA denial issued by MHP or MDHHS FFS Pharmacy Services.
• For MHP denials: complete MHP internal appeal first (typically 30–45 days per MHP contract).
• After MHP appeal denial OR for FFS denials: file MOAHR fair-hearing request within 120 days using form MDHHS-5617-MAHS.
• Form URL: michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder31/ Folder2/Folder131/Folder1/Folder231/MDHHS-5617-MAHS.dot
• Hearings: Administrative Law Judges, typically by phone for recipient cases.
• Toll-free hotline: 1-800-648-3397.
• LARA general inquiry: 517-335-7519.

Realistic scope of fair-hearing success: a challenge to the BMI ≥ 40 gate itself is unlikely to succeed because the gate is mandated by Public Act 22 of 2025, a duly-enacted state appropriations statute. The Administrative Law Judge cannot override a legislative mandate. The most viable challenges are: (a) EPSDT-based challenges for adolescents under 21; (b) procedural-fairness challenges to MHP-level PA-denial reasoning that misapplied MDHHS criteria; and (c) clinical-judgment disputes where the prescriber documents morbid obesity and bariatric-surgery-avoidance attestation but the MHP denied on other grounds. Questions about hearings: MDHHSPharmacyServices@michigan.gov.

Related research in this series

• Illinois Medicaid GLP-1 coverage (2026): the strictest-exclusion state — doubly-anchored on 89 IAC § 140.441(b) + HFS PDL absence, no weight-management carve-back-in — The closest structural comparator to Michigan within the cluster. Both states impose tight effective gates for weight-management GLP-1 coverage; Illinois through a pre-GLP-1-era administrative regulation (89 IAC § 140.441(b) “Anorectic drugs or combinations including such drugs”, last amended May 30, 2014) with no coverage pathway at any BMI; Michigan through a 2025 appropriations statute that retains a narrow morbid-obesity carve-out with the uniquely Michigan bariatric-surgery-avoidance prescriber attestation. Illinois has no MASH, MACE, or OSA carve-back-in; Michigan has all three. Reading these two states side by side shows the structural difference between a standing regulatory exclusion and an appropriations-statute-driven restriction.
• Ohio Medicaid GLP-1 coverage (2026): triple-anchored weight-loss exclusion + the January 2026 Wegovy MACE/MASH carve-back-in — The most useful comparator for Michigan’s non-obesity indication pathways. Both states have MACE and MASH carve-back-ins for Wegovy effective January 2026. Key differences: Ohio’s MACE pathway excludes T1D/T2D (A1C < 6.5%); Michigan does not. Ohio’s Gainwell SPBM gate has no chronic-weight-management pathway at any BMI; Michigan retains one at BMI ≥ 40. Ohio’s authority is a triply-anchored combination of OAC 5160-9-03(B)(1) regulation, Gainwell SPBM operational notice, and federal statute; Michigan’s restriction is driven entirely by an appropriations statute and is therefore structurally more reversible via the appropriations cycle.
• Pennsylvania Medicaid GLP-1 coverage (2026): policy reversal — terminated all chronic-weight-management coverage January 1, 2026 — The sharpest contrast to Michigan in the cluster. Pennsylvania (Pattern #7) terminated ALL GLP-1 chronic-weight-management coverage effective January 1, 2026, saving an estimated $266.684 million per year in state funds, while Michigan retained the narrow morbid-obesity gate. PA’s authority is 55 Pa. Code § 1121.54 plus MAB2025112403 — an administrative regulation anchor that Michigan lacks. PA explicitly excluded Saxenda for adolescents; Michigan preserved both Wegovy and Saxenda for adolescents 12–17 at the morbid-obesity threshold. Both states enacted their changes effective January 1, 2026 and are among the largest state Medicaid programs to restructure GLP-1 obesity coverage simultaneously.
• New York Medicaid (NYRx) GLP-1 coverage and Wegovy MACE pathway (2026) — Michigan’s closest structural twin for the morbid-obesity coverage pathway. Both NY and MI set BMI ≥ 40 as the chronic-weight-management floor. Key differences: NY’s authority is the longstanding 18 NYCRR § 505.3(g)(3) state regulation (predating the GLP-1 era); Michigan’s is a 2025 appropriations statute. NY adds a lifetime two-attempt cap for the BMI ≥ 40 Wegovy pathway; Michigan has no cap. Michigan’s uniquely Michigan bariatric-surgery-avoidance prescriber attestation has no New York analogue.
• GLP-1 insurance dropped coverage appeal playbook — the four-phase appeal logic; for Michigan Medicaid members, the Michigan MOAHR fair-hearing process (MDHHS-5617-MAHS form, 120-day window, 1-800-648-3397) substitutes for the commercial-plan internal-appeal pathway. The most viable Michigan-specific challenges are: EPSDT for adolescents, procedural-fairness for MHP-level criteria misapplication, and clinical-judgment disputes where morbid obesity and bariatric attestation are documented but the MHP denied on other grounds.
• GLP-1 insurance coverage across Medicare, Medicaid, and commercial plans — the federal-state framework and how Michigan’s five-class PDL structure (T2D, MACE, MASH, OSA, and weight management as separate PDL classes) compares to other states’ more consolidated GLP-1 coverage architectures.
• Wegovy alternatives 2026 — for Michigan Medicaid members at BMI 27–39 who do not qualify for the morbid-obesity pathway and are evaluating Zepbound, Foundayo, Saxenda, and the cash-pay compounded-semaglutide landscape. Michigan’s $240 million GLP-1 pharmaceutical-appropriations reduction means some of the ~18,000 weight-management-only users will transition to the cash-pay compounded market.
• GLP-1 prior-authorization letter generator — supports documentation of the Michigan-specific five-class step-therapy ladder (benzphetamine + diethylpropion + orlistat + phendimetrazine + phentermine trial-and-failure documentation) and the bariatric-surgery-avoidance prescriber attestation in a Letter of Medical Necessity template.

Last verified: May 10, 2026. Michigan Medicaid GLP-1 PA criteria: Prime Therapeutics Clinical Criteria version 05012026v1, effective May 1, 2026. PDL classifications per the Michigan Single PDL effective May 1, 2026. Check mi.primetherapeutics.com for updates. State policy changes can occur between the article’s verification date and the date you are reading it; this article is not a substitute for individualized coverage verification with your MHP or MDHHS FFS Pharmacy Services.