Data investigation
Nevada Medicaid GLP-1 Coverage 2026: Pattern #31 — Statutory-Mandate-Failed Categorical-Exclusion State with Sole Wegovy CV-Only Carve-Out (Most Restrictive in Series) — Statewide MCO Expansion + Single PDL January 1, 2026 — Nevada Health Authority Reorganization July 1, 2025 — SB 244 Died June 3, 2025
Nevada Medicaid (Nevada Health Authority, formerly DHCFP, reorganized July 1, 2025 under SB 494) DOES NOT cover GLP-1 receptor agonists for chronic weight management. Categorical exclusion anchored in Pharmacy Manual § 3.7 ('Agents used for weight loss') + 42 U.S.C. § 1396r-8(d)(2)(A). Single PDL (eff. Nov 1, 2025 / Jan 1, 2026, administered by Magellan/Prime Therapeutics) omits Wegovy, Zepbound, Saxenda, Foundayo, Qsymia, Contrave, phentermine, orlistat entirely — no anti-obesity drug class exists. Health Plan of Nevada (UHC subsidiary) explicitly lists 'Anti-obesity agents' among three Plan Exclusions. SOLE carve-out: Wegovy for MACE cardiovascular risk reduction (Web Announcement 3337, April 22, 2024) — age ≥ 18, BMI ≥ 27, established CVD (MI/stroke/PAD), NO T1DM/T2DM, 1-year PA approval — the most restrictive Wegovy-CV architecture of any Wegovy-CV state in 31-state series. No MASH carve-out, no Zepbound-OSA carve-out, no Imcivree carve-out despite FDA Aug 8, 2025 Wegovy-MASH approval and Dec 20, 2024 Zepbound-OSA approval. SSSB 19-month non-action streak (June 2024 → Dec 2025). SB 244 (2025 Regular Session, Senators Lange/Nguyen/Cruz-Crawford) died June 3, 2025 — DHCFP projected $165.4M biennium cost ($64.3M General Fund). Concurrent Jan 1, 2026 transitions: ~75K rural FFS→MCO + Single PDL. Five MCOs: Anthem (Clark/Washoe), CareSource (rural + Clark/Washoe, new Apr 2025), HPN/UHC (Clark only), Molina (Clark/Washoe), SilverSummit/Centene (rural + Clark/Washoe). PBM: Magellan/Prime Therapeutics (PA phone 800-695-5526, fax 844-347-3202). T2DM GLP-1s covered: Ozempic/Trulicity/Victoza/Rybelsus/Byetta preferred; Mounjaro/liraglutide-generic non-preferred (PA + CC + QL). Pattern #31 in 50-state series. Last verified 2026-05-10.
- Nevada Medicaid
- Nevada Health Authority
- NVHA
- GLP-1 Medicaid coverage
- Pharmacy Manual § 3.7
- Wegovy MACE only
- Web Announcement 3337
- Single PDL November 2025
- Magellan Prime Therapeutics
- Silver State Scripts Board SSSB
- SB 244 died
- SB 494 NVHA reorganization
- statewide MCO expansion
- CareSource new entrant
- 50-state Medicaid series
- Pattern #31
50-State Medicaid Series · Pattern #31 · Last verified 2026-05-10
Nevada Medicaid GLP-1 Coverage (2026): Sole Wegovy Cardiovascular-Risk-Reduction Carve-Out — Most Restrictive Wegovy-CV State in Series — NO Chronic-Weight-Management Coverage
Nevada Medicaid — now administered by the Nevada Health Authority (NVHA), formerly the Division of Health Care Financing and Policy (DHCFP), reorganized July 1, 2025 under SB 494 — does not cover GLP-1 receptor agonists for adult chronic weight management. The exclusion is anchored in Pharmacy Manual § 3.7 (“Agents used for weight loss”), reinforced by the Single PDL’s complete omission of all anti-obesity agents, and operationally confirmed by the Health Plan of Nevada’s verbatim “Anti-obesity agents” Plan Exclusion. Nevada has one carve-out: Wegovy for FDA-approved MACE cardiovascular risk reduction (Web Announcement 3337, April 22, 2024) — no MASH, no Zepbound-OSA, no Imcivree, no Saxenda, no Foundayo. Of every state in this 31-state series that covers Wegovy for the MACE indication (NY, AL, WA, OK, NV), Nevada is the most restrictive: only one carve-out, no extension to new FDA indications for 19 months. Legislative mandate failed: SB 244 (2025) died in money committee June 3, 2025 after DHCFP projected a $165.4 million biennium cost.
TL;DR — What Nevada Medicaid Actually Covers
Nevada Medicaid GLP-1 coverage summary (Single PDL eff. Nov 1, 2025 / Jan 1, 2026):
| Drug | Covered? | Indication / Notes |
|---|---|---|
| Wegovy (semaglutide injection) | MACE only | PA required. Age ≥ 18, BMI ≥ 27, established CVD (MI/stroke/PAD), NO T1DM/T2DM. Web Announcement 3337, Apr 22, 2024. 1-year approval. |
| Wegovy — weight management | NOT covered | Pharmacy Manual § 3.7 categorical exclusion. No PDL listing. |
| Wegovy — MASH | NOT covered | No SSSB carve-out despite FDA Aug 8, 2025 MASH approval. |
| Zepbound (tirzepatide) | NOT covered | Absent from Single PDL. No OSA carve-out. Not covered for any indication. |
| Saxenda, Foundayo, Qsymia, Contrave, orlistat, phentermine | NOT covered | None on Single PDL for weight management. |
| Ozempic, Trulicity, Victoza, Rybelsus, Byetta (T2DM) | COVERED | Preferred on Single PDL, PA + QL. Type-2 diabetes indication only. |
| Mounjaro (tirzepatide, T2DM) | COVERED | Non-preferred, PA + CC + QL. T2DM only. Trial of one preferred agent required. |
Read This First: Nevada Is NOT on the KFF “Covering” List
Unlike Washington Apple Health — which is classified by KFF as covering GLP-1s for obesity despite a clear operational exclusion — Nevada Medicaid is straightforward: KFF’s January 2026 tracker does NOT list Nevada among the covering states. The record is unambiguous.
The YMYL risk is subtler: some patients assume that because Wegovy has FDA approval for cardiovascular risk reduction AND Nevada Medicaid covers it for that indication, Wegovy must therefore also be accessible for weight loss through Nevada Medicaid. It is not. The Web Announcement 3337 carve-out is exclusively gated on the MACE indication. A patient with obesity and no established cardiovascular disease has no Wegovy pathway through Nevada Medicaid, regardless of BMI. A patient with T2DM and established CVD also has no Wegovy pathway — the PA criteria explicitly require absence of T1DM and T2DM.
For context on the broader pattern in this series, see GLP-1 insurance coverage across Medicare, Medicaid, and commercial plans.
Pharmacy Manual § 3.7 Categorical Exclusion
The operational anchor for Nevada Medicaid’s GLP-1 weight-loss exclusion is Section 3.7 of the Nevada Medicaid and Nevada Check Up Pharmacy Manual (“Covered and Non-Covered Drugs”), administered by Prime Therapeutics. Verbatim:
“The Nevada Medicaid Drug Rebate Program will not reimburse for the following pharmaceuticals:
- Agents used for weight loss
- Agents used to promote fertility
- Agents used for cosmetic purposes or hair growth
- Yohimbine
- Drug Efficacy Study and Implementation (DESI) list ‘Less than Effective Drugs’
- Pharmaceuticals considered ‘Experimental’ as to substance or diagnosis for which prescribed
- Pharmaceuticals manufactured by companies not participating in the federal Medicaid Drug Rebate Program unless rated ‘1-A’ by the FDA
- Agents used for impotence/erectile dysfunction”
Source: Nevada Medicaid and Nevada Check Up Pharmacy Manual, Section 3.7, administered by Prime Therapeutics Management LLC, verified via direct PDF fetch from nv.primetherapeutics.com 2026-05-10.
The phrase “Agents used for weight loss” is the categorical bar. This phrasing is operationally narrower than the federal authority at 42 U.S.C. § 1396r-8(d)(2)(A)(“Agents when used for anorexia, weight loss, or weight gain”) — Nevada omits “anorexia” and “weight gain” from its exclusion language. The practical effect: the exclusion applies exclusively to weight-loss-purpose use. Agents prescribed for non-weight-loss indications (e.g., Wegovy for MACE cardiovascular risk reduction) are not captured by the exclusion and require a separate coverage determination.
Unlike Oklahoma’s OAC 317:30-5-72.1(1)(D) (which builds in “unless otherwise specified” carve-out language) and Alabama’s Ala. Admin. Code r. 560-X-16-.01(2)(b) (which is a regulatory-level exclusion), Nevada’s exclusion is in the Pharmacy Manual — operationally below the regulatory level but directly binding on the Prime Therapeutics PBM for claims adjudication. The Wegovy MACE carve-out operates not by exception language in § 3.7 but by regulatory characterization: Wegovy prescribed for MACE is not “used for weight loss.”
Single PDL Omission of Wegovy, Zepbound, Saxenda, and Foundayo
The Nevada Medicaid Single Preferred Drug List (sPDL), effective November 1, 2025 (extended to statewide January 1, 2026 alignment per Web Announcement 3787, December 10, 2025), confirms the categorical exclusion operationally: the sPDL contains no anti-obesity drug class. The PDL header states verbatim:
“Nevada Medicaid’s PDL only includes select drug classes.”
The 148B Incretin Mimetics and Combinations class (under Hormones and Hormone Modifiers) contains only T2DM-indicated agents:
| Preferred (PA + QL) | Non-Preferred (PA + CC + QL) |
|---|---|
| Byetta (exenatide) | Bydureon BCise (exenatide ER) |
| Ozempic (semaglutide injection) | exenatide (generic) |
| Rybelsus (semaglutide oral) | liraglutide (generic) |
| Trulicity (dulaglutide) | Mounjaro (tirzepatide) |
| Victoza (liraglutide) | Soliqua; Xultophy |
Source: Nevada Medicaid Single PDL, Section 148B Incretin Mimetics and Combinations, effective November 1, 2025. Verbatim from nv.primetherapeutics.com, verified 2026-05-10.
Wegovy, Zepbound, Saxenda, Imcivree, Foundayo (orforglipron), Qsymia, Contrave, phentermine, orlistat, and Xenical are absent from every class in the Single PDL. There is no “Anti-Obesity Medications” or “Weight Management Agents” therapeutic class. The PDL covers 19 therapeutic classes; none addresses obesity treatment. This is the operational confirmation of the Pharmacy Manual § 3.7 exclusion at the formulary level.
The sPDL footnote for Incretin Mimetics reads: “Trial of only one agent is required before moving to a non-preferred agent. MSM 1200 - Appendix A section: KK. Incretin Mimetics.” This step-therapy gate applies to T2DM-indication prescriptions only.
Sole Carve-Out: Wegovy CV (Web Announcement 3337)
Nevada Medicaid’s one and only GLP-1 anti-obesity drug coverage pathway is the Wegovy cardiovascular risk-reduction carve-out, established by Web Announcement 3337, dated April 22, 2024. This is the most restrictive Wegovy-CV architecture of any state in the 31-state series: no MASH extension, no Zepbound-OSA extension, no Imcivree carve-out — just one carve-out, held static for 19 months through all four SSSB quarterly meetings that followed.
Full verbatim text of Web Announcement 3337:
“Wegovy (semaglutide) Coverage Updates Based on New FDA-Labeled Indication
On March 8, 2024, the FDA announced the approval of a new indication for use of Wegovy (semaglutide) injection to reduce the risk of cardiovascular death, heart attack, and stroke in obese or overweight adults with established cardiovascular disease. Wegovy should be used in addition to a reduced calorie diet and increased physical activity.
See the FDA announcement for full recommendations.
Nevada Medicaid has updated policy to include coverage of Wegovy for this new indication in recipients who meet required prior authorization criteria in-line with FDA package labeling.”
Source: Nevada Medicaid Web Announcement 3337, “Wegovy (semaglutide) Coverage Updates Based on New FDA-Labeled Indication,” April 22, 2024. Verified via direct PDF fetch from medicaid.nv.gov 2026-05-10.
Per Magellan Rx Nevada Medicaid provider portal PA criteria, the Wegovy MACE prior authorization requires ALL of the following:
- Prescribed for risk reduction of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke)
- Age ≥ 18 years
- BMI ≥ 27 kg/m²
- Established cardiovascular disease (history of MI, stroke, or symptomatic peripheral arterial disease)
- Patient does NOT have type 1 or type 2 diabetes — patients with T1DM or T2DM must use an alternative therapy; this indication is specific to non-diabetic patients
- PA approval is valid for one year
The “no T1DM/T2DM” gate is critical: a patient with established CVD who also has T2DM cannot use the Wegovy MACE pathway. That patient would need to use an Ozempic or Trulicity (T2DM-indicated) prescription, with the cardiovascular benefit flowing as a secondary effect of diabetes treatment — not as a direct Wegovy MACE authorization.
Nevada’s BMI threshold (≥ 27 kg/m²) matches the FDA’s Wegovy MACE label and is operationally equivalent to Oklahoma’s threshold. This is more permissive than New York’s NYRx PA criteria (which use BMI ≥ 40) but consistent with the FDA label.
What the carve-out does NOT cover:
- Wegovy for noncirrhotic MASH — the FDA approved Wegovy for MASH on August 8, 2025; Nevada has taken no SSSB action as of 2026-05-10
- Zepbound for moderate-to-severe OSA — FDA approved December 20, 2024; Nevada has taken no SSSB action
- Imcivree (setmelanotide) for monogenic obesity — no PA criteria document exists in Nevada Medicaid
- Foundayo (orforglipron) — FDA approved August 14, 2025 for chronic weight management; not on Single PDL
Nevada Health Authority Reorganization (July 1, 2025)
On July 1, 2025, Nevada Medicaid was operationally reorganized under Senate Bill 494 of the 2025 Regular Session, signed by Governor Joe Lombardo June 11, 2025. The Division of Health Care Financing and Policy (DHCFP) became the Nevada Health Authority (NVHA). The full announcement, verbatim from Web Announcement 3661 (July 1, 2025):
“Nevada Health Authority is Official and DHCFP Becomes Nevada Medicaid Effective July 1, 2025
Carson City, NV — We are excited to announce that the Nevada Health Authority (NVHA) is officially on its way with the Governor’s signature on June 11, 2025, to enact Senate Bill 494 and launching on July 1, 2025. The Division of Health Care Financing and Policy can now officially go by its common name Nevada Medicaid.
The goals of this new Department have been resoundingly clear since the beginning: unify similarly aligned agencies to leverage the purchasing power of Medicaid, lower healthcare costs for Nevadans, bring more providers to the state, improve health care quality and streamline Medicaid eligibility.”
Source: Nevada Medicaid Web Announcement 3661, July 1, 2025. Verified via direct PDF fetch 2026-05-10.
NVHA is led by Administrator Stacie Weeks (formerly Nevada Medicaid administrator). NVHA consolidates Nevada Medicaid, Medicaid eligibility (from DWSS), the Patient Protection Commission, Public Employees’ Benefits Program, Silver State Health Insurance Exchange (NevadaHealthLink.com), Office of Analytics, Governor’s Council on Developmental Disabilities, Graduate Medical Education, Waiver Provider Oversight, and Health Care Quality and Compliance.
SB 494 did NOT amend NRS 422.4025 for anti-obesity medication coverage, nor did it alter the Pharmacy Manual § 3.7 categorical exclusion. Legacy regulatory citations to “DHCFP” remain operationally valid. URLs at dhcfp.nv.gov redirect to nevadamedicaid.nv.gov.
Concurrent Dual Transition: January 1, 2026
Nevada is the only state in this 31-state series to execute two simultaneous Medicaid operational changes on the same date:
- Statewide Managed Care Expansion — approximately 75,000 rural Nevadans who were served through fee-for-service (FFS) were enrolled in one of the five MCOs effective January 1, 2026. Rural Nevadans had two MCO choices: CareSource (new entrant, awarded April 2025 — the first new MCO entrant since 2017) and SilverSummit Healthplan (Centene subsidiary).
- Single PDL Alignment — all five MCOs aligned their formularies to the FFS pharmacy program’s Single PDL effective January 1, 2026, per Web Announcement 3787 (December 10, 2025).
Web Announcement 3787 (December 10, 2025) announced the sPDL transition verbatim:
“Beginning on January 1, 2026, Nevada Medicaid will transition to a Single Preferred Drug List (sPDL) to create a more consistent and streamlined approach to medication coverage. This change is designed to improve access to medications, reduce administrative complexity, and support better coordination of care across all programs. …
Legacy Coverage Period: To support this transition, there will be a temporary coverage period beginning January 1, 2026, through June 30, 2026, allowing members to continue their current prescriptions. This will give time for providers and members to adjust and, when appropriate, switch to a preferred medication.”
Source: Nevada Medicaid Web Announcement 3787, December 10, 2025. Verified via direct PDF fetch 2026-05-10.
The Legacy Coverage Period (January 1 – June 30, 2026) means that any member holding a legacy MCO PA approval for a non-sPDL medication will continue through June 30, 2026 or the original authorization’s expiration date, whichever is earlier. SilverSummit’s single PDL FAQ confirmed: “All prior authorizations that were approved prior to the implementation of a single PDL will be valid through the expiration date on the authorization or 6/30/26, whichever comes first.” After June 30, 2026, the sPDL governs exclusively.
The Five MCOs Effective January 1, 2026
Nevada Medicaid operates five MCOs as of January 1, 2026. All five align their pharmacy formularies to the Single PDL. Key service-area distinctions:
| MCO | Clark | Washoe | Rural | Phone |
|---|---|---|---|---|
| Anthem BCBS NV | ✓ | ✓ | ✗ | 844-396-2329 |
| CareSource NV (new Apr 2025) | ✓ | ✓ | ✓ | 833-230-2058 |
| Health Plan of Nevada (HPN/UHC) | ✓ | ✗ | ✗ | 800-962-8074 |
| Molina Healthcare NV | ✓ | ✓ | ✗ | 833-685-2102 |
| SilverSummit (Centene) | ✓ | ✓ | ✓ | 844-366-2880 |
Source: Nevada Medicaid Web Announcement 3753, October 24, 2025. Verified 2026-05-10.
The Health Plan of Nevada Medicaid PDL — the largest urban MCO (UnitedHealthcare subsidiary, Clark County only) — contains the most explicit MCO-level categorical exclusion in this 31-state series. Verbatim from its “Plan Exclusions” section:
“PLAN EXCLUSIONS
The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the Health Plan of Nevada Medicaid PDL.
- DESI drugs
- Anti-obesity agents
- Experimental / research drugs”
Source: Health Plan of Nevada Medicaid PDL “Plan Exclusions” section, verified via direct PDF fetch from myhpnmedicaid.com 2026-05-10.
HPN’s GLP-1 entries under Antidiabetic Agents list only T2DM-indicated drugs (liraglutide Tier 1, Mounjaro Tier 2, Ozempic Tier 2, Rybelsus Tier 2, Victoza Tier 2 — all with PA + QL). No Wegovy. No Zepbound. No Saxenda.
One notable outlier: Anthem’s NV Medicaid PDLlists ALLI (OTC orlistat 60 mg) with PA, OTC, and QL flags under an “ADHD/Anti-Narcolepsy/Anti-Obesity/ Anorexiants” class header. ALLI is the only anti-obesity agent with a PDL listing at any Nevada MCO. This does NOT constitute Wegovy or Zepbound coverage — it is a legacy OTC listing that predates the current sPDL alignment. The Pharmacy Manual § 3.7 categorical exclusion applies to the state program regardless of this Anthem-specific listing.
PBM: Magellan/Prime Therapeutics
Nevada Medicaid’s FFS pharmacy benefit has been administered by Magellan Medicaid Administration (MMA), a division of Magellan Rx Management (subsequently acquired by Prime Therapeutics in 2022 and now operating as Prime Therapeutics Management LLC), since July 1, 2022. The operational portal is at nv.primetherapeutics.com.
PA contact information (FFS + all five MCOs):
- Phone: 800-695-5526
- PA fax: 844-347-3202
- PA forms / ePA: nv.primetherapeutics.com (CoverMyMeds integration)
Future PBM transition: Section 12 of Chapter 390 of the 2025 Statutes of Nevada (amending NRS 422.4053) authorizes NVHA to contract with a “state pharmacy benefit manager.” This transition has not been executed as of 2026-05-10 — Magellan/Prime Therapeutics remains the operational PBM contractor. The effective date provisions in NRS 422.4025, 422.4032, and 422.4053 are conditioned on the effective date of the initial state-PBM contract, which has not been signed.
SSSB: 19-Month Non-Action Streak on MASH/OSA
The Silver State Scripts Board (SSSB) — Nevada’s Pharmacy and Therapeutics Committee under NRS 422.4035 — meets quarterly and votes on PDL changes. In the four most recent verified quarterly meetings:
- June 20, 2024 (Web Announcement 3387) — no GLP-1 anti-obesity action
- September 26, 2024 (Web Announcement 3458) — added liraglutide generic to Incretin Mimetics (T2DM only); no Wegovy MASH/Zepbound OSA action
- September 18, 2025 (Web Announcement 3757) — no GLP-1 anti-obesity action; this meeting came after the August 8, 2025 FDA Wegovy-MASH approval and the August 14, 2025 FDA Foundayo approval
- December 11, 2025 (Web Announcement 3825) — no GLP-1 anti-obesity action
This 19-month non-action streak (from the April 2024 Wegovy-CV carve-out through December 2025) distinguishes Nevada from Colorado, Oklahoma, Connecticut, and Alabama — all of which added at least one new FDA-label carve-out (MASH or OSA) in 2024–2025. No future SSSB meeting outcomes should be predicted.
SB 244 (2025) Died in Committee
The most significant recent legislative development is the failure of Senate Bill 244 of the 83rd Nevada Legislature (2025 Regular Session) — titled “AN ACT relating to Medicaid; requiring Medicaid to cover certain treatments for obesity and the services of certain programs for the prevention of diabetes.”
Sponsorship (verbatim from enrolled bill):
“SENATE BILL NO. 244 – SENATORS LANGE, NGUYEN, CRUZ-CRAWFORD; FLORES AND TAYLOR — FEBRUARY 26, 2025. Referred to Committee on Health and Human Services.”
Sponsors: Sen. Roberta Lange (D-Las Vegas), Sen. Rochelle Nguyen (D-Las Vegas), Sen. Michelee Cruz-Crawford (D-Las Vegas), Asm. Edgar Flores (D-Las Vegas), Asm. Angela Taylor (D-Las Vegas).
The bill’s operative mandate, verbatim from Section 1:
“1. To the extent that federal financial participation is available, the Director shall include under Medicaid coverage for:
(a) Treatment for obesity, including, without limitation, coverage of:
(1) Intensive health, behavior and lifestyle treatment; and
(2) Any surgical intervention included in the most current Guidelines on Indications for Metabolic and Bariatric Surgery published by the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders; and
(b) The services of a diabetes prevention program for recipients of Medicaid …”
Section 2 amended NRS 422.4025 to add a new subsection (4)(c), verbatim:
“(c) Prescription drugs approved by the United States Food and Drug Administration with an indication for chronic weight management in patients who have been diagnosed with obesity.”
Section 2 subsection (8) added the operative coverage mandate:
“8. The Medicaid program must cover the drugs described in paragraph (c) of subsection 4 to the extent that such drugs are prescribed in accordance with the indications of the United States Food and Drug Administration.”
Section 5 set an effective date of January 1, 2026 — the same date as the statewide MCO expansion and the Single PDL.
Source: SB 244 enrolled text, 83rd Nevada Legislature (2025 Regular Session), verified via direct PDF fetch from archive.leg.state.nv.us 2026-05-10.
Why it failed:
The Nevada Division of Health Care Financing and Policy (DHCFP) projected the bill would cost $165.4 million over the 2025–2027 biennium— with $64.3 million from the Nevada General Fund and approximately $101.1 million in federal share. The bill died in money committee on June 3, 2025without reaching a floor vote.
Senate HHS Committee Chair Sen. Fabián Doñate expressed reservations about pharmaceutical-industry influence and prescribing guardrails (per Nevada Current, March 19, 2025):
“How can we ensure there are guardrails up, that the prescriptive treatments are actually medically necessary versus saying that any doctor can just recommend?”
“If I’m a pharmaceutical company and a state were to pass this requirement, the first thing I would do is send as many representatives that I could.”
Dr. Steven Shane, pediatric obesity specialist at Renown Children’s Hospital (testifying March 19, 2025), described the clinical stakes:
“I typically cannot provide the best evidence-based therapies because Medicaid does not cover these options.”
“It is no different than not covering other diseases such as asthma, diabetes or even cancer.”
No 2026 successor legislation has been introduced as of 2026-05-10.
Appeals: NHA Fair Hearings
Nevada Medicaid members denied a GLP-1 prescription have two primary administrative remedies:
- MCO internal appeal — for members in any of the five MCOs. Must be filed within 60 days of the MCO’s adverse action notice. The MCO must issue a decision within 45 days (standard) or 3 days (expedited clinical urgency).
- Nevada Health Authority Fair Hearing — available after an adverse MCO appeal decision, or for FFS-served members after a PA denial. Request must be filed within 90 days of the adverse action. Fair hearings are conducted by the NVHA Hearings Office (formerly DHCFP Office of Administrative Hearings). Judicial review follows under NRS Chapter 233B (Administrative Procedures Act).
Practical guidance for Wegovy MACE appeals: If a member meets all criteria (age ≥ 18, BMI ≥ 27, established CVD, no T1DM/T2DM) but received a denial, the most likely cause is incomplete documentation. Resubmit with verbatim chart documentation of the prior MI, stroke, or symptomatic PAD event plus a clear indication statement. Contact Prime Therapeutics PA line (800-695-5526) to clarify documentation requirements before filing a formal appeal.
For chronic-weight-management denials: No operational PA pathway exists. The categorical exclusion applies categorically. The only remaining options are a pediatric EPSDT case-by-case medical-necessity exception (applicable only to members under 21) or waiting for a future legislative or SSSB action. For strategies applicable when any insurer drops GLP-1 coverage, see the GLP-1 insurance dropped-coverage appeal playbook.
How Nevada Compares: Most Restrictive Wegovy-CV State
Of the five states in this series that cover Wegovy for the MACE indication, Nevada’s architecture is the most restrictive:
| State | Wegovy MACE | Wegovy MASH | Zepbound OSA | Imcivree | BMI threshold (MACE) |
|---|---|---|---|---|---|
| Nevada (NV) #31 | ✓ | ✗ | ✗ | ✗ | ≥ 27 kg/m² |
| NY #3 | ✓ | ✗ | ✗ | ✓ | ≥ 40 kg/m² (stricter than label) |
| AL #23 | ✓ | ✗ | ✓ | ✗ | ≥ 27 kg/m² |
| WA #14 | ✓ | ✓ | ✓ | ✗ | ≥ 27 kg/m² |
| OK #24 | ✓ | ✓ | ✓ | ✓ | ≥ 27 kg/m² |
NY and NV are structurally the closest analogs: both have a Wegovy-CV-only DUR-Board carve-out layered over a categorical exclusion. Key differences: NY’s exclusion is anchored at the regulatory level (18 NYCRR § 505.3(g)(3)); NV’s is at the Pharmacy Manual level. NY requires BMI ≥ 40 for MACE (stricter than the FDA label and than NV’s ≥ 27); NY also covers Imcivree for monogenic obesity while NV does not.
WA is the closest operational analog on the “covers-Wegovy-CV-but-not-general-weight-management” dimension. WA’s coverage is broader (MACE + MASH + Zepbound OSA); NV’s is more restrictive (MACE only). Both are Medicaid programs that a naive KFF-read might miscategorize. As noted, Washington Apple Health (Pattern #14) is on the KFF covering list as a YMYL trap; Nevada is not.
AL is the closest analog on exclusion architecture with two carve-outs. NV is structurally one carve-out behind AL — NV has MACE, AL has MACE plus Zepbound-OSA. NV’s exclusion is Pharmacy Manual level; AL’s is regulatory (Ala. Admin. Code r. 560-X-16-.01(2)(b)).
What Nevada Medicaid Patients Can Do in 2026
- Confirm your MCO. Call the NVHA member line (Medicaid@nvha.nv.gov) or visit nevadamedicaid.nv.gov to confirm your plan. If you are a rural member who transitioned on January 1, 2026, your MCO is either CareSource (833-230-2058) or SilverSummit (844-366-2880).
- If you have established CVD (prior MI, stroke, or symptomatic PAD) AND no diabetes: Ask your prescriber to submit a Wegovy MACE prior authorization via Prime Therapeutics (phone 800-695-5526, fax 844-347-3202, or ePA at nv.primetherapeutics.com). Provide documented chart evidence of your CVD history.
- If you have type-2 diabetes: Ozempic (semaglutide injection), Trulicity, Victoza, and Rybelsus are covered as Preferred agents on the Single PDL. Mounjaro (tirzepatide) is covered as a non-preferred agent with PA and clinical criteria (trial of one preferred agent required). The cardiovascular benefit of these agents flows through the T2DM indication.
- If you are seeking coverage for chronic weight management only: No operational pathway exists in Nevada Medicaid as of 2026-05-10. Consider exploring whether your provider’s practice has access to Novo Nordisk’s or Eli Lilly’s patient assistance programs, or telehealth providers with sliding-scale pricing.
- Monitor SSSB meeting schedules. The Silver State Scripts Board meets quarterly. A future SSSB action could add Wegovy-MASH or Zepbound-OSA carve-outs without legislative action. SSSB meeting announcements are published at nevadamedicaid.nv.gov.
Sources
- Nevada Medicaid and Nevada Check Up Pharmacy Manual, Section 3.7 “Covered and Non-Covered Drugs.” Prime Therapeutics Management LLC. nv.primetherapeutics.com. Verified 2026-05-10.
- Nevada Medicaid Single Preferred Drug List (sPDL), effective November 1, 2025. Section 148B Incretin Mimetics and Combinations. nv.primetherapeutics.com/cms/nvm/static-assets/documents2/pdl/NV_SPDL_11.01.25.pdf. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3337, “Wegovy (semaglutide) Coverage Updates Based on New FDA-Labeled Indication,” April 22, 2024. medicaid.nv.gov/Downloads/provider/web_announcement_3337_20240422.pdf. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3787, “Nevada Medicaid is Implementing a Single Preferred Drug List (sPDL),” December 10, 2025. medicaid.nv.gov/Downloads/provider/web_announcement_3787_20251210.pdf. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3661, “Nevada Health Authority is Official and DHCFP Becomes Nevada Medicaid Effective July 1, 2025,” July 1, 2025. medicaid.nv.gov/Downloads/provider/web_announcement_3661_20250701.pdf. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3753, “Statewide Managed Care Questions and Answers,” October 24, 2025. medicaid.nv.gov/Downloads/provider/web_announcement_3753_20251024.pdf. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3757, Silver State Scripts Board changes effective November 1, 2025. Verified 2026-05-10.
- Nevada Medicaid Web Announcement 3825, Silver State Scripts Board changes effective February 1, 2026. Verified 2026-05-10.
- Health Plan of Nevada Medicaid PDL, “Plan Exclusions” section. myhpnmedicaid.com/content/dam/hpnv-public-sites/myhpnmedicaid/documents/provider/nv-provider-pdl.pdf. Verified 2026-05-10.
- SilverSummit Healthplan Single PDL FAQ. silversummithealthplan.com. Verified 2026-05-10.
- Senate Bill 244, 83rd Nevada Legislature (2025 Regular Session). Enrolled text. archive.leg.state.nv.us/Session/83rd2025/Bills/SB/SB244.pdf. Verified 2026-05-10.
- Senate Bill 494, 83rd Nevada Legislature (2025 Regular Session). Nevada Health Authority Act. Signed June 11, 2025; effective July 1, 2025. Verified 2026-05-10.
- 42 U.S.C. § 1396r-8(d)(2)(A). Federal optional exclusion authority for “Agents when used for anorexia, weight loss, or weight gain.” Cornell LII, law.cornell.edu. Verified 2026-05-10.
- NRS 422.4025 (“The Department shall, by regulation, develop a list of preferred prescription drugs”). Nevada Revised Statutes. leg.state.nv.us. Verified 2026-05-10.
- NRS 422.4035, 422.405. Silver State Scripts Board statutory authority. Verified 2026-05-10.
- Nevada Current, March 19, 2025. Senate Health and Human Services Committee testimony on SB 244. Sponsoring-senator and Sen. Doñate verbatim quotes. Verified 2026-05-10.
Frequently Asked Questions
Does Nevada Medicaid cover Wegovy (semaglutide) for weight loss in 2026?
No. Nevada Medicaid's Pharmacy Manual § 3.7 categorically excludes 'Agents used for weight loss' and the Single PDL omits Wegovy, Zepbound, Saxenda, Foundayo, Qsymia, Contrave, phentermine, and orlistat entirely. Wegovy is covered ONLY for the FDA-approved MACE cardiovascular indication (Web Announcement 3337, April 22, 2024) — not for chronic weight management, not for MASH, not for any other indication.
What is the one situation where Nevada Medicaid DOES cover Wegovy?
Nevada Medicaid covers Wegovy with prior authorization for reduction of major adverse cardiovascular events (MACE) in adults age 18+, BMI ≥ 27 kg/m², established cardiovascular disease (history of MI, stroke, or symptomatic peripheral arterial disease), AND NO type 1 or type 2 diabetes. The PA is approved for one year. This carve-out was created by Web Announcement 3337 on April 22, 2024 following the FDA's March 8, 2024 MACE approval and has not been extended to MASH or OSA indications.
Does Nevada Medicaid cover Zepbound (tirzepatide) for sleep apnea?
No. Zepbound is omitted entirely from the Nevada Medicaid Single PDL effective November 1, 2025. Unlike Alabama, Oklahoma, Colorado, and Connecticut — which all have Zepbound-OSA carve-outs — Nevada has not added this carve-out despite the FDA's December 20, 2024 Zepbound-OSA approval. As of 2026-05-10, the Silver State Scripts Board has taken no action on Zepbound-OSA coverage.
Which MCO serves me if I am a Nevada Medicaid member in a rural county?
As of January 1, 2026, two MCOs serve rural Nevada Medicaid members: CareSource of Nevada (new entrant, first since 2017) and SilverSummit Healthplan (Centene subsidiary). Anthem, Health Plan of Nevada (UHC), and Molina serve only Clark and/or Washoe counties. Rural members who were in fee-for-service were enrolled in one of these two MCOs on January 1, 2026. Call Medicaid at Medicaid@nvha.nv.gov or call CareSource (833-230-2058) or SilverSummit (844-366-2880) with questions.
How do I submit a prior authorization for Wegovy MACE coverage in Nevada Medicaid?
Submit via Prime Therapeutics: phone 800-695-5526, fax 844-347-3202, or electronic PA (ePA) at nv.primetherapeutics.com via CoverMyMeds. Required documentation: prescription for cardiovascular event risk reduction, age ≥ 18, BMI ≥ 27 kg/m², documented history of MI, stroke, or symptomatic peripheral arterial disease, AND confirmation of no T1DM or T2DM diagnosis. PA approvals are valid for one year.
What happened to Nevada SB 244, the GLP-1 Medicaid coverage bill?
Senate Bill 244 of the 2025 Regular Session — the 'Diabetes Prevention and Obesity Treatment Act' sponsored by Senators Roberta Lange, Rochelle Nguyen, and Michelee Cruz-Crawford plus Assembly co-sponsors Edgar Flores and Angela Taylor — died in money committee on June 3, 2025. The Nevada Division of Health Care Financing and Policy projected it would cost $165.4 million over the 2025–2027 biennium ($64.3 million from Nevada's General Fund). No successor legislation has been introduced as of 2026-05-10.
How do I appeal a Nevada Medicaid denial for a GLP-1 prescription?
For MCO members: file an internal MCO appeal within 60 days of the adverse action notice. If that is denied, request a Nevada Health Authority Fair Hearing within 90 days of the adverse MCO decision. For FFS members: request a Fair Hearing with the NVHA Hearings Office within 90 days. Judicial review of an adverse hearing decision is available in Nevada District Court under NRS Chapter 233B. For chronic-weight-management denials specifically, no operational PA pathway exists — the categorical exclusion applies.
Is the Nevada Health Authority the same as DHCFP, or is it a new agency?
Senate Bill 494 of the 2025 Regular Session reorganized DHCFP (the Division of Health Care Financing and Policy) into the new Nevada Health Authority (NVHA), effective July 1, 2025, per Web Announcement 3661. The operating agency is now NVHA, led by Administrator Stacie Weeks. Legacy documents (NAC, MSM Chapter 1200) still reference 'DHCFP' — those citations remain operationally valid but the operating brand is now Nevada Medicaid under NVHA.