New York Medicaid (NYRx) GLP-1 Coverage (2026): Triple-Anchored Weight-Loss Exclusion + the Wegovy MACE Pathway

New York Medicaid — branded NYRx, the Medicaid Pharmacy Program — is the fourth-largest US Medicaid program (~7M enrollees). It has the strongest-evidenced weight-loss-drug exclusion in our 50-state Medicaid series so far: triple-anchored by federal statute (42 U.S.C. § 1396r-8(d)(2)(A)), state regulation (18 NYCRR § 505.3(g)(3)), AND explicit drug-brand-named NYRx contractor documentation. The NYRx Drug Class Coverage Overview (Rev. 04/23/2026) names the brands directly: “GLP-1 agonists, including but not limited to Ozempic, Wegovy, and Mounjaro are excluded from coverage for weight loss indications.” NYRx covers Ozempic, Trulicity, Victoza (BLTG-Preferred), and exenatide as Preferred GLP-1s for type 2 diabetes; Mounjaro, Rybelsus, Bydureon BCise, liraglutide-generic, Soliqua, and Xultophy are Non-Preferred (PA required). Wegovy is covered ONLY for the FDA-approved MACE-reduction indication via a separate Drug Utilization Review (DUR) entry — and the NYRx PA criteria are stricter than the FDA Wegovy MACE label: NYRx requires BMI ≥ 40 kg/m² (FDA label allows ≥ 27 with established CVD), six months of documented adherence to cardiovascular therapy and lifestyle modifications, AND a lifetime limit of TWO TREATMENT ATTEMPTS. Zepbound, Saxenda, and Foundayo are NOT listed anywhere on the April 23, 2026 NYRx PDL. KFF's January 2026 tracker lists New York among the 13 states “covering GLP-1s for obesity treatment under fee-for-service” — but that classification is anchored solely to the narrow Wegovy MACE pathway, NOT to chronic-weight-management coverage.

What NYRx covers (the bottom line)

NYRx, the centralized statewide fee-for-service pharmacy benefit that absorbed every mainstream Managed Care, Health and Recovery Plan (HARP), and HIV-SNP outpatient pharmacy benefit on April 1, 2023, takes a narrow position on GLP-1 receptor agonists. As of the April 23, 2026 revision:

• T2D-indicated GLP-1s on the PDL: Preferred = exenatide, Ozempic, Trulicity, Victoza (BLTG-Preferred); Non-Preferred (PA required) = Bydureon BCise, liraglutide (gen Victoza), Mounjaro, Rybelsus, Soliqua, Xultophy. Class Clinical Criteria require confirmation of an FDA-approved or compendia-supported Medicaid-covered indication — in practice, a documented type 2 diabetes diagnosis — and PA when used concurrently with a DPP-IV inhibitor.
• Wegovy for MACE reduction (cardiovascular event reduction): covered via a separate Drug Utilization Review (DUR) entry on PDL page 74 with a lifetime quantity limit of two treatment attempts and PA criteria stricter than the FDA Wegovy MACE label (BMI ≥ 40, six months of CVD-therapy adherence, six months of comprehensive lifestyle modifications). Operationalized through the 11-question Wegovy NYRx PA Form (Rev. 10/30/25).
• Wegovy for chronic weight management: excluded by name in the NYRx Drug Class Coverage Overview. No PA pathway exists.
• Zepbound, Saxenda: NOT listed anywhere on the April 23, 2026 NYRx PDL. No PA pathway exists.
• Imcivree (setmelanotide): the only obesity-indicated drug with a published NYRx PA pathway, restricted to monogenic / syndromic genetic obesity (POMC, PCSK1, LEPR deficiency or Bardet-Biedl syndrome).
• Foundayo (orforglipron, LillyDirect): out-of-scope for NYRx. Foundayo is a cash-pay direct-to-consumer brand from Eli Lilly that does not bill insurance. PDL status is irrelevant to the Foundayo patient pathway.

The triple-anchored exclusion authority — federal statute, state regulation, AND explicit drug-brand-named NYRx contractor documentation — is the single most distinguishing feature of New York's Medicaid GLP-1 weight-loss policy. It is the strongest-evidenced exclusion in our 50-state Medicaid series so far, stronger than the California 2025-26 budget reversal (which rests on a single budget instrument plus the federal authority) and stronger than the Texas operational silence (which rests on the federal authority plus a Superior HealthPlan provider notice).

The triple-anchored weight-loss exclusion

Three independent layers of legal authority invoke and reinforce New York's exclusion of GLP-1 receptor agonists for the weight-loss indication. Each layer is verbatim-quoted from a verified primary-source document.

Layer 1 — Federal authority: 42 U.S.C. § 1396r-8(d)(2)(A)

Federal Medicaid drug-coverage rules permit — but do not require — states to exclude certain enumerated categories of drugs from coverage. The category that matters for Wegovy, Saxenda, and Zepbound (when prescribed for chronic weight management) is at 42 U.S.C. § 1396r-8(d)(2)(A). Verbatim:

“Agents when used for anorexia, weight loss, or weight gain.”

This is one of seven enumerated optional-exclusion categories in the statute. The federal floor: states may decline Medicaid coverage of any drug when prescribed for one of these uses. The federal ceiling: states may elect to cover them anyway — nothing prohibits state coverage. New York has elected to use the optional exclusion for weight-loss-indication GLP-1s.

Layer 2 — State regulation: 18 NYCRR § 505.3(g)(3)

New York's exclusion is anchored a second time in state regulation. The April 2022 New York State Medicaid Update (Volume 38 Number 4), “Reminder: Some Drug Categories are Excluded from Coverage in Pharmacy and Medical Benefits,” states verbatim:

“The New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) programs cover an extensive drug benefit providing access to medically necessary drugs. There are, however, certain drug/drug classes that are not covered by Medicaid for certain diagnoses due to federal or state rules, as outlined in both the Social Security Act §1927(d)(2), located on the Social Security Administration ‘Payment for Covered Outpatient Drugs’ website and in the eMedNY New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines document. This article serves as a reminder of those exclusions for both the FFS and MMC program areas, which are as follows: agents when used for the treatment of anorexia, weight loss or weight gain [additionally pursuant to New York Code, Rules and Regulations (NYCRR) Title 18 §505.3(g)(3)].”

18 NYCRR § 505.3(g)(3) is the state-regulation hook. NY Insurance Law generally regulates commercial health insurance, not Medicaid; NY Medicaid coverage rules flow from federal Social Security Act § 1927 and state authorities at NY Social Services Law § 365-a and 18 NYCRR § 505.3. The 18 NYCRR § 505.3(g)(3) regulatory citation is what makes New York's exclusion structurally different from states like Florida (which invoke the federal exclusion by operational silence rather than by an explicit state- regulation hook).

Layer 3 — NYRx contractor verbatim brand-name exclusion

The third layer is the most operationally specific. The NYRx Drug Class Coverage Overview for GLP-1 Receptor Agonists – Type 2 Diabetes (originally published 09/13/2023, revised 04/23/2026 by Prime Therapeutics State Government Solutions LLC) names the excluded brands directly. Verbatim:

“Note: NYRx, the Medicaid pharmacy program, covers medically necessary FDA-approved drugs when used for Medicaid-covered indications. Certain drugs, drug classes, or drug indications including weight loss are excluded from coverage pursuant to federal or state law and regulation. Exclusions include agents when used for the treatment of anorexia, weight loss, or weight gain [18 NYCRR§505.3(g)(3)]. Weight loss is not and never has been a Medicaid-covered indication. GLP-1 agonists, including but not limited to Ozempic, Wegovy, and Mounjaro are excluded from coverage for weight loss indications. Editing has been enhanced to ensure that members with Medicaid-covered indications have access to these medications. For more information, please refer to the NYRx Excluded Diagnoses.”

Three things to note about this third-layer language:

1. The exclusion is explicit by drug brand name. Ozempic, Wegovy, and Mounjaro are named directly. The phrase “including but not limited to” extends the exclusion across the entire GLP-1 class for the weight-loss indication.
2. NYRx represents that “Editing has been enhanced” to enforce the exclusion. This is a reference to the NYRx claims-processing edit logic at point of sale. Pharmacies attempting to dispense a GLP-1 for a weight-loss indication will receive a claim rejection if the diagnosis on the claim does not match a Medicaid- covered indication for that GLP-1.
3. “Weight loss is not and never has been a Medicaid-covered indication” is a clear policy statement of permanence under current authorities. This contrasts with California — where Medi-Cal Rx previously covered GLP-1 anti-obesity medications and reversed the policy effective January 1, 2026 via the enacted state budget. New York's exclusion has not recently changed direction; the verbatim NYRx position is that the exclusion has been continuous.

YMYL hedging boundary on the triple-anchor framing: we describe the legal authority for New York's exclusion as triple-anchored because three independent primary-source documents converge on the same exclusion outcome. We do NOT opine on the constitutional or administrative-law basis of any single layer, do NOT predict the outcome of pending legislation that could change any layer (see Pending NY legislation), and do NOT promise any specific PA outcome based on a member's individual clinical facts.

The narrow Wegovy MACE pathway (DUR-CV only)

New York Medicaid covers Wegovy for exactly one indication: the FDA-approved cardiovascular event reduction (MACE) indication, approved by the FDA on March 8, 2024 for adults with established cardiovascular disease and either obesity or overweight. This is operationalized through the NYRx Drug Utilization Review (DUR) section, page 74 of the April 23, 2026 NYRx PDL. Verbatim DUR entry:

“semaglutide (Wegovy®)
LIFETIME QUANTITY LIMIT:
• Two treatment attempts per lifetime
Additional / Alternate Parameter(s):
• Confirm diagnosis of cardiovascular disease
• Confirm patient BMI of ≥ 40kg/m²
• Confirm patient is participating in lifestyle modifications that support cardiovascular health.”

This DUR entry is the only place Wegovy appears anywhere on the April 23, 2026 NYRx PDL. Three structural facts to note:

1. Wegovy is NOT listed in the GLP-1 T2D class. The Endocrine and Metabolic Agents section of the PDL (where the GLP-1 T2D Preferred and Non-Preferred drugs are listed) does NOT include Wegovy. Coverage is restricted to the cardiovascular event reduction indication via the separate DUR entry above.
2. The NYRx BMI threshold (≥ 40 kg/m²) is materially stricter than the FDA Wegovy MACE label. The FDA label requires BMI ≥ 27 with established cardiovascular disease. NYRx imposes BMI ≥ 40 as a state-level utilization control, not as an FDA-label restatement. Members with BMI 27–39 and established CVD may meet the FDA label criteria for Wegovy MACE but do NOT meet the NYRx PA criteria. This is a NY-specific stricter-than-label gate.
3. The lifetime quantity limit of two treatment attempts is a NY-specific cap. A patient who has attempted Wegovy twice in their lifetime — whether through NYRx, prior commercial coverage, prior Medicare coverage, or any other payer — is not eligible for a third NYRx Wegovy approval. There is no FDA-label parallel to this lifetime cap. Patients failing or discontinuing Wegovy twice cannot retry.

The 11-question Wegovy NYRx Prior Authorization Request Form

The DUR entry above is operationalized through the NYRx Wegovy® Prior Authorization Request Form, Revision Date 10/30/25, copyrighted 2025 by Prime Therapeutics State Government Solutions LLC. The form is 5 pages and 11 numbered clinical questions. Verbatim from the form instructions (page 1):

“Refer to the drug utilization review section on the NYRx Preferred Drug List (PDL) for Wegovy® clinical criteria requirements. Please fill out all sections completely and legibly.”

Initial diagnostic gate — verbatim from page 2 (questions 1-4):

“1. What diagnosis is this being prescribed for? Diagnosis #1: ICD-10 Code: Diagnosis #2: ICD-10 Code:
2. Does the member have type 1 or type 2 diabetes mellitus? Yes / No
3. Does the member have established cardiovascular disease? Yes / No If Yes, provide the specific cardiovascular diagnosis:
4. Is the member using any other GLP-1 agonist therapy at this time? Yes / No”

Question 4 is the anti-stockpiling check at the PA stage — concurrent GLP-1 use blocks the Wegovy approval (see the dedicated Anti-stockpiling rules section below).

Initiation of therapy criteria — verbatim from page 3 (questions 5-8):

“5. What is the member's BMI at the initiation of therapy (kg/m²):
6. Is the member adherent to established prescribed cardiovascular disease (CVD) therapy (antihypertensive, lipid-lowering agent, and anti-thrombotic agent, or platelet aggregation inhibitor) for at least six months prior to initiating therapy? Yes / No If Yes, provide the current CVD therapy: If No, provide the clinical rationale:
7. Does the prescriber attest that the member has participated in comprehensive lifestyle modifications that encourage behavioral modifications, a reduced calorie diet and increased physical activity starting at least six months prior to initiating therapy and with continued treatment? Yes / No If No, provide the clinical rationale:
8. Does the prescriber attest that the member will continue comprehensive lifestyle modifications that encourage behavioral modifications, a reduced calorie diet and increased physical activity? Yes / No”

Continuation of therapy criteria — verbatim from page 4 (questions 9-11):

“9. Has the member been adherent to Wegovy? Note: Adherent to Wegovy is defined as consistent use with no lapses in therapy via NYRx and/or any previous insurer. Yes / No
10. Does the member remain adherent to established prescribed CVD therapy (antihypertensive, lipid-lowering agent, and anti-thrombotic agent, or platelet aggregation inhibitor)? Yes / No
11. Has the member attempted to use Wegovy for the reduction of MACE (major adverse cardiovascular events) two or more times in their lifetime? Yes / No If Yes, provide the clinical rationale:”

Question 11 is where the NYRx lifetime two-attempts cap is enforced operationally. A “Yes” answer requires clinical rationale — without persuasive rationale, the PA is denied as exceeding the lifetime cap.

False Claims attestation (page 5):

“Submission of this form confirms the information is accurate and true, and that the supporting documentation is available for review upon request of the New York State Department of Health or the Centers for Medicare & Medicaid Services. The submitter understands that any person who knowingly makes or causes to be made a false record to statement that is material to a Medicaid claim may be subject to civil penalties and treble damages under both the federal and New York State False Claims Acts.”

YMYL boundary on the Wegovy MACE pathway: we do not promise approval for any specific patient. Coverage approvals are individual and clinical-fact-dependent. The NYRx PA criteria above are stricter than the FDA Wegovy MACE label and members who meet the FDA label criteria do not automatically meet the NYRx criteria. The lifetime cap of two treatment attempts is a NY-specific utilization control with no FDA-label parallel. Members and prescribers should consult the NYRx Clinical Call Center at 1-877-309-9493 (24/7) for case-specific PA guidance.

T2D-indicated GLP-1 coverage (Preferred and Non-Preferred)

For type 2 diabetes mellitus, NYRx covers the GLP-1 receptor agonist class as a Preferred / Non-Preferred matrix on the April 23, 2026 PDL. Verbatim from the GLP-1 T2D class entry in Section VI. Endocrine and Metabolic Agents:

The class-level Clinical Criteria, verbatim from the PDL:

“CLINICAL CRITERIA (CC)
• Confirm diagnosis of FDA-approved or compendia-supported indication and Medicaid covered indication
• PA required for patients utilizing a GLP-1 and DPP-IV concurrently”

And the class-level coverage scope, verbatim from the NYRx Drug Class Coverage Overview Rev. 04/23/26:

“Drugs in the Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists – Type 2 Diabetes drug class are included on the NYRx Preferred Drug List (PDL) and are subject to prior authorization (PA) requirements of the NYRx Preferred Drug Program. When clinically appropriate, use of preferred agents is associated with comparable clinical outcomes and a significantly lower total cost of care. Non-preferred agents are often two to ten times more costly than preferred alternatives.”

The PA-trigger logic:

“• Preferred drugs will not require PA if the required coverage parameters are found in the member's Medicaid claim history at the time of pharmacy claim submission. Providers should include all applicable diagnosis codes in a member's electronic medical record (EMR) and submit their claims in a timely manner to decrease the need to manually obtain a PA.
• Non-preferred drugs will require PA.
• All drugs in the GLP-1 agonists drug class are subject to Clinical Criteria (CC). CC must confirm the diagnosis of FDA-approved, compendia-supported, Medicaid-covered indication.”

Important YMYL caveat: NYRx does NOT publish standalone HbA1c thresholds, fixed metformin trial-and-failure requirements, BMI thresholds, age thresholds, or step-therapy criteria for the GLP-1 T2D class on the PDL itself. Unlike Texas (where the Acentra PDL Criteria Guide enumerates a 14-day failed-trial-of-preferred-agent rule) or Florida (which publishes HbA1c ≥ 6.5% + metformin trial-and-failure), New York's class CC is more general. Substantive clinical detail beyond the “Medicaid covered indication” standard is not publicly enumerated for the T2D indication. Members and prescribers should call the NYRx Clinical Call Center for case-specific PA guidance.

Drugs not on the NYRx PDL: Zepbound, Saxenda, Foundayo

Three commonly prescribed weight-management GLP-1 / dual- agonist brands do NOT appear anywhere on the April 23, 2026 NYRx PDL:

• Wegovy (semaglutide for chronic weight management, no CV indication): not listed as Preferred or Non-Preferred. The only Wegovy entry on the PDL is the DUR cardiovascular pathway (BMI ≥ 40 + CVD + 6mo therapy + lifetime two-attempts cap). Wegovy for chronic weight management without a CVD diagnosis is explicitly excluded by the NYRx Drug Class Coverage Overview Rev. 04/23/26: “GLP-1 agonists, including but not limited to Ozempic, Wegovy, and Mounjaro are excluded from coverage for weight loss indications.”
• Zepbound (tirzepatide for chronic weight management or obstructive sleep apnea): not listed anywhere on the PDL. No NYRx PA pathway exists. (The same molecule — tirzepatide — is on the PDL as Mounjaro for T2D only.)
• Saxenda (liraglutide 3 mg for chronic weight management): not listed anywhere on the PDL. No NYRx PA pathway exists. (The same molecule — liraglutide — is on the PDL as Victoza/generic for T2D 1.8 mg dose only. Saxenda is the obesity-dose 3 mg formulation and is not addressed.)
• Foundayo (orforglipron, LillyDirect): out-of-scope for NYRx. Foundayo is a cash-pay direct-to- consumer brand from Eli Lilly that does not bill insurance. PDL status is irrelevant to the Foundayo patient pathway.

YMYL hedging boundary on Zepbound for OSA. Zepbound was FDA-approved in December 2024 for moderate-to- severe obstructive sleep apnea in adults with obesity. As of the April 23, 2026 NYRx PDL revision, NYRx has not published a Zepbound prior-authorization pathway for the OSA indication. Patients and providers should expect a case-by-case Miscellaneous-Drug-Criteria-equivalent review under the master Clinical Criteria standard (“Confirm diagnosis of FDA-approved or compendia-supported indication and Medicaid covered indication”). Whether NYRx will treat the Zepbound OSA indication as a Medicaid-covered indication parallel to the Wegovy CV pathway is not addressed in any verified primary source as of 2026-05-09. We do not promise OSA-indication coverage outcomes.

Imcivree (setmelanotide) — the only obesity-indicated drug with a published NYRx PA pathway

For the small clinical population with confirmed monogenic / syndromic genetic obesity (POMC, PCSK1, LEPR deficiency or Bardet-Biedl syndrome), the NYRx PDL Drug Utilization Review section at page 68 publishes a PA pathway for Imcivree (setmelanotide). Verbatim entry:

“Imcivree™ (setmelanotide)
• Confirm diagnosis of FDA-approved or compendia-supported indication and Medicaid covered indication
• Please be prepared to respond to a series of questions that identify the prescriber, the patient, and the reason for prescribing this drug.
• Please be prepared to fax clinical documentation upon request.

The Imcivree fax form can be found at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PA_Worksheet_Prescribers_Imcivree.pdf”

Imcivree is NOT a GLP-1; it is an MC4 receptor agonist for genetic obesity. It is included here because it is the only obesity-indicated drug with a published NYRx PA pathway and therefore the only NYRx route to a covered anti-obesity medication for the small clinical population with confirmed pathogenic genetic variants. Members evaluating Imcivree should consult the prescribing physician and a genetic counselor to confirm whether their clinical presentation meets the FDA-label genetic-confirmation requirement.

Anti-stockpiling rules (NY-specific, apply to ALL GLP-1s)

New York Medicaid imposes anti-stockpiling rules unique among the four large-state Medicaid programs we have audited in this 50-state series. These rules apply to all GLP-1 prescriptions — whether Preferred, Non-Preferred, or under the Wegovy DUR cardiovascular pathway. Verbatim from the NYRx Drug Class Coverage Overview Rev. 04/23/26:

“• NYRx does not cover more than one GLP-1 agonist or more than one strength of the same GLP-1 agonist at a time. To reduce overutilization, stockpiling, and/or diversion of drugs, pharmacies will receive a rejection when submitting claims for more than one GLP-1 agonist or more than one strength of the same GLP-1 agonist while the patient still has greater than 25% of a current fill remaining.”

“• Proper claim submission: Claims for GLP-1 agonists should be submitted based on the total days' supply for the quantity dispensed. For example, a prescription with a quantity of 4 to be administered once per week should be submitted as a 28-day supply. Failure to submit claims with accurate days' supply may result in claim rejection.”

“• Dose titration: subsequent prescriptions for dose titration will not pay until 25% or less supply of the previous prescription remains.”

“• If a prescriber determines a need to switch the patient's treatment or dose while the patient still has greater than 25% of a current fill remaining, the prescriber may request a prior authorization from the NYRx clinical call center.”

Operational consequences for members:

1. No concurrent GLP-1 fills. A member cannot be on Ozempic and Mounjaro simultaneously, cannot be on two strengths of Ozempic simultaneously, and cannot be on a T2D-indicated GLP-1 plus Wegovy under the cardiovascular pathway simultaneously. The pharmacy claim will be rejected at point of sale.
2. Dose titration is gated by the 25% rule. When titrating up (e.g., Ozempic 0.25 mg to 0.5 mg to 1 mg), the next-strength prescription will not pay until 25% or less of the previous-strength supply remains. A member with a 28-day supply of Ozempic 0.25 mg cannot fill the 0.5 mg titration prescription until day 22 or later (with 7 or fewer days of the 0.25 mg supply remaining).
3. Mid-fill switches require a separate PA. A member who has already filled a 28-day supply of one GLP-1 and whose prescriber wants to switch to a different GLP-1 mid-cycle (because of GI side effects, dosage intolerance, or clinical preference) must request a separate PA from the NYRx Clinical Call Center at 1-877-309-9493 (24/7). The PA can authorize the switch but is not automatic.
4. Anti-stockpiling enforcement is automated at the pharmacy. The 25%-of-current-fill threshold is calculated from the NYRx claims-history record. Pharmacies do not have discretion to override the rejection at point of sale. The PA workaround is the only escalation pathway.

These anti-stockpiling rules are NOT present in the Texas, California, or Florida Medicaid primary sources we have audited. They are NY-specific. Patients moving from a non- NYRx pharmacy benefit (e.g., commercial insurance or another state's Medicaid) to NYRx may encounter a 25%-rule rejection on their first NYRx fill if their prior fill supply has not yet exceeded the 75% threshold. Patients in that scenario should call the NYRx Clinical Call Center for a transition-of-care PA.

The NYRx carve-out (April 1, 2023) — why plan-level divergence is structurally impossible

Effective April 1, 2023, New York State carved the entire outpatient pharmacy benefit out of mainstream Managed Care into a single statewide fee-for-service pharmacy program branded NYRx, the Medicaid Pharmacy Program. Verbatim from the New York State Medicaid Update March 2023 NYRx Pharmacy Benefit Transition Part Three Special Edition (Volume 39 Number 4):

“Effective April 1, 2023, New York State (NYS) Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through NYRx, the Medicaid Pharmacy Program [formerly known as Medicaid fee-for-service (FFS)], instead of through their MMC Plan. The pharmacy benefit transition to NYRx does not apply to NYS Medicaid members enrolled in Managed Long-Term Care (MLTC) Plans [e.g., MLTC, Programs of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), the Essential Plan (EP), or Child Health Plus (CHP)].”

The DOH-stated rationale, verbatim:

“Transitioning the pharmacy benefit from MMC to NYRx will provide NYS with full visibility into prescription drug costs, allow centralization of the benefit, leverage negotiation power, and provide a uniform list of covered drugs with standardized utilization management protocols simplifying and streamlining the drug benefit for NYS Medicaid members. NYS Medicaid members have comprehensive drug coverage and equitable access to an extensive network of over 5,000 pharmacy providers.”

Why this matters for GLP-1 PA: regardless of which mainstream MMC plan administers a Medicaid beneficiary's medical benefit — Healthfirst, MetroPlusHealth, Fidelis Care (Centene), EmblemHealth, MVP Health Care, Excellus BlueCross BlueShield, UnitedHealthcare Community Plan, or any other plan — all outpatient pharmacy PA decisioning is consolidated into NYRx. The NYRx PDL is the operative coverage list. Plan-level divergence (a beneficiary getting better PA criteria by switching from Fidelis to MetroPlus, or vice versa) is structurally impossible for mainstream MMC, HARP, and HIV-SNP enrollees.

Plan-level confirmation comes from explicit deferral language on the largest NYS MCO pharmacy pages. Verbatim from Healthfirst (the largest NYC-area Medicaid MCO):

“Beginning April 1, 2023, all Medicaid members enrolled in Healthfirst Medicaid Managed Care or Personal Wellness Plan will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.”

And from MetroPlusHealth (the NYC public-hospital plan):

“Beginning April 1, 2023, all Medicaid members enrolled in MetroPlusHealth Medicaid, Partnership In Care, and Enhanced (HARP) plans will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.”

And from Fidelis Care (Centene's NY MCO):

“Pharmacy benefits administered by NYRx, the Medicaid Fee-for-Service (FFS) Pharmacy Program.”

Populations NOT subject to the NYRx carve-out

The NYRx carve-out does NOT apply to:

• Managed Long-Term Care (MLTC) plans
• Programs of All-Inclusive Care for the Elderly (PACE)
• Medicaid Advantage Plus (MAP)
• the Essential Plan (EP)
• Child Health Plus (CHP)

For these populations, pharmacy benefits remain managed by the enrollee's plan (or, for the Essential Plan and CHP, by separate state-managed programs). Members enrolled in MLTC, PACE, MAP, the Essential Plan, or Child Health Plus are NOT subject to the NYRx GLP-1 rules described in this article. The NYRx PDL, the Wegovy DUR cardiovascular pathway, and the anti-stockpiling rules above do not directly govern those populations' outpatient pharmacy adjudication.

NYRx contractor structure

The New York State Department of Health has contracted with Prime Therapeutics State Government Solutions LLC (which acquired the legacy Magellan Medicaid Administration government-services book of business in 2024) to administer NYRx clinical operations and PA decisioning. Verbatim from the NYRx contractor portal:

“The Department of Health has contracted with Prime Therapeutics State Government Solutions to assist with management of the PDP.”

The newyork.fhsc.com domain is the legacy First Health Services Corporation / Magellan Medicaid Administration contractor portal — Prime Therapeutics retained the domain after the acquisition. Members and prescribers should treat newyork.fhsc.com as the authoritative source for current PDL, PA forms, and clinical-criteria documentation.

NYRx contact lines (verbatim):

• NYRx Education & Outreach Call Center: 1-833-967-7310 (M-F 8 AM - 5 PM ET, excluding holidays); email NYRxEO@primetherapeutics.com
• NYRx Clinical Call Center: 1-877-309-9493 (24/7)
• Standard PA fax: 1-800-268-2990

How NY's exclusion differs from Texas, California, and Florida

New York is the third state we have published a deep-dive Medicaid GLP-1 article on (after Texas and California), with Florida queued as the fourth. The four states are the four largest Medicaid populations in the United States (California ~13M, Texas ~5.5M, Florida ~5M, New York ~7M) and together account for roughly one-third of all US Medicaid enrollees. Each state has elected to use the federal weight-loss optional exclusion at 42 U.S.C. § 1396r-8(d)(2)(A), but with materially different operational mechanics:

New York is structurally most similar to California — both have centralized statewide carve-outs that consolidate all mainstream-MMC outpatient pharmacy PA decisioning into a single state PBM. But the exclusion authority is more layered in NY (triple-anchored vs California's budget- instrument plus federal-statute pairing), and NY's Wegovy MACE pathway has materially stricter PA criteria than California's case-by-case CV pathway.

KFF's “13 states” classification — what it actually means for NY

KFF's January 16, 2026 state-by-state Medicaid GLP-1 coverage tracker reports:

“13 state Medicaid programs covered GLP-1s for obesity treatment under fee-for-service (FFS) as of January 2026.”

Per KFF's tracker, the 13 states are: Arkansas, Colorado, Connecticut, Delaware, Illinois, Louisiana, Massachusetts, Minnesota, New Mexico, New York, Oregon, Virginia, and Washington. (KFF identifies California, New Hampshire, Pennsylvania, and South Carolina as states that “eliminated coverage of GLP-1s for obesity treatment” between the October 2025 KFF survey and the January 2026 publication.)

Critical caveat for NY readers. KFF's classification of New York as one of the 13 “covering GLP-1s for obesity treatment” states is anchored solely to the Wegovy cardiovascular pathway we documented above. That pathway requires:

• BMI ≥ 40 kg/m² (not BMI ≥ 27 with CVD as the FDA label allows)
• Established cardiovascular disease with documented diagnosis
• Six months of documented adherence to CVD therapy (antihypertensive + lipid-lowering + anti-thrombotic / platelet aggregation inhibitor)
• Six months of comprehensive lifestyle modifications (reduced calorie diet + increased physical activity) prior to initiation, with continued adherence required
• A lifetime quantity cap of two treatment attempts

This is materially narrower than the chronic-weight-management coverage envisioned by KFF's survey question. New York does NOT cover Wegovy or any other GLP-1 for the chronic-weight-management indication absent established cardiovascular disease. Members searching “does NY Medicaid cover Wegovy for weight loss” will see KFF's 13-state classification and may incorrectly conclude that chronic-weight-management coverage is available. It is not. The KFF classification is technically accurate — NY does cover Wegovy for what is technically an obesity-adjacent indication (the FDA-approved MACE-reduction indication) — but the practical access pathway is gated by BMI ≥ 40, established CVD, and the lifetime cap.

YMYL framing for NY readers: if you are searching for NY Medicaid Wegovy coverage and you do NOT have established cardiovascular disease or you have BMI below 40, the KFF classification does not apply to your clinical picture. The chronic-weight-management indication is excluded by the triple-anchored authority described above. If you DO have established cardiovascular disease with BMI ≥ 40 and have been adherent to CVD therapy and lifestyle modifications for at least six months, the Wegovy MACE pathway may apply — but each PA is reviewed individually and approval is not guaranteed.

Pending NY legislation (historical context only — nothing has changed coverage)

Three pending New York 2025-2026 Session bills would explicitly mandate NYRx coverage of FDA-approved GLP-1 receptor agonist medications for chronic weight management. As of the publication date of this article, all four bills remain in committee and none has been enacted. We include them as historical context, not as a coverage pathway Medicaid beneficiaries can rely on. (Bill metadata captured via BillTrack50 and WebSearch indexed snippets; the nysenate.gov primary HTML is Cloudflare-walled to programmatic agents and bill text was not directly verifiable in our verifier session.)

• Assembly Bill A09360 (Santabarbara, December 19, 2025): per the BillTrack50 detail page, the bill would amend NY Social Services Law to require Medicaid coverage of FDA-approved GLP-1 receptor agonist medications for obesity (BMI ≥ 30, or ≥ 27 with related health complications), metabolic disorders (prediabetes and type 2 diabetes), and autism-related compulsive eating behaviors. Status as of 2026-05-09: introduced 12/19/2025; referred to Health Committee 01/07/2026. Has not advanced.
• Senate Bill S5798 (Sen. Sepulveda): per WebSearch indexed snippet, the bill would add a new section (§ 368-g) to the Social Services Law requiring Medicaid managed care plans to cover FDA-approved weight-loss medications for chronic weight management in adults with obesity who have at least one weight-related condition. Companion to A09360 in the NY Senate.
• Assembly Bill A2715 / Senate Bill S3104: per WebSearch indexed snippet, the bills would require comprehensive Medicaid coverage for the treatment of obesity, defined as including intensive behavioral therapy, bariatric surgery, AND FDA-approved anti-obesity medications. Allows utilization management to determine medical necessity, but requires those determinations to be made in the same manner as for other medical conditions.

Important hedging. We do not predict the passage prospects of any of these bills. We do not promise readers that NY weight-loss GLP-1 coverage is imminent. Passage prospects depend on session calendar, fiscal note, and committee dynamics that are not addressed in any verified primary source we have captured. NY's 2025-2026 session runs through January 2027. Until and unless one of these bills is enacted, New York Medicaid does not cover GLP-1 receptor agonists for the chronic- weight-management indication.

How to appeal a NYRx denial

If NYRx denies a GLP-1 PA, the member has two principal escalation pathways: (a) the New York State Department of Health Office of Health Insurance Programs administrative review process (member-services and state-provided fair- hearing rights), and (b) the New York State Office of the Medicaid Inspector General (OMIG) compliance complaint process for suspected adjudication errors.

The standard appeal pathway for an NYRx PA denial is a Fair Hearing administered by the New York State Office of Temporary and Disability Assistance (OTDA). Members should request the Fair Hearing within the time window stated on their Notice of Action (NOA) — typically 60 days from the NOA date for Medicaid fair-hearing rights, though the member should consult the specific time window stated on their NOA.

Operational notes about NYRx denial appeals:

1. A Fair Hearing cannot fix a policy-level determination. Wegovy / Zepbound / Saxenda for weight-loss indications are excluded as a matter of NYRx policy under the triple-anchored authority described above (federal statute + 18 NYCRR § 505.3(g)(3) + NYRx contractor documentation). A Fair Hearing is unlikely to overturn a properly adjudicated weight-loss-indication denial — the determination is policy-level, not clinical.
2. Where a Fair Hearing CAN help is in the case-by-case PA framework: a Wegovy MACE-pathway denial where the member believes the BMI / CVD-therapy / lifestyle documentation was misadjudicated; an Imcivree denial where the genetic-confirmation documentation was misadjudicated; or an anti-stockpiling 25%-rule denial where the prior-fill calculation was incorrect. These adjudication-error appeals may be reversed at the Fair Hearing level.
3. Before filing a Fair Hearing, request a written denial letter from NYRx, request the verbatim PA criteria the denial cited, and have the prescriber draft a Letter of Medical Necessity (LOMN) that engages with the specific clause cited. Generic LOMN templates that do not engage with the specific verbatim NYRx criteria typically fail.
4. For non-pharmacy issues (e.g., medical benefit denials, plan eligibility, dental, vision), members should contact their MMC plan's member services directly — the NYRx carve-out applies only to the outpatient pharmacy benefit.
5. NYRx-specific case-handling questions should go to the NYRx Education & Outreach Call Center at 1-833-967-7310 (M-F 8 AM - 5 PM ET) or the NYRx Clinical Call Center at 1-877-309-9493 (24/7).

For the broader appeal mechanics that apply across payers — including what to include in a Letter of Medical Necessity, how to engage with the verbatim policy clause cited in the denial, and how to coordinate a Fair Hearing with the prescriber's office — see our GLP-1 insurance dropped coverage appeal playbook. The four-phase appeal logic in that playbook applies directly to NYRx PA denials, with the OTDA Fair Hearing substituted for the commercial-plan internal-appeal pathway.

For patients without coverage: cash-pay options

New York Medicaid beneficiaries whose weight-management GLP-1 prescription is not covered by NYRx — and beneficiaries for whom the case-by-case PA pathway will not succeed — have several manufacturer- and retailer-direct cash-pay options that do not require insurance. Verified 2026-05-09:

• NovoCare Pharmacy (Wegovy). Novo Nordisk self-pay program. Wegovy 0.25 / 0.5 / 1.0 / 1.7 / 2.4 mg single-dose pens at $299/month for cash-pay patients who do not have insurance or whose insurance does not cover Wegovy. Order through novocare.com.
• LillyDirect Self Pay Pharmacy (Zepbound). Eli Lilly direct-to-consumer vials. Zepbound 2.5 / 5 / 7.5 / 10 / 12.5 / 15 mg vials at $299–$449/month depending on dose strength. Ordered through lillydirect.com.
• LillyDirect / Amazon Pharmacy (Foundayo). Eli Lilly oral GLP-1 (orforglipron tablets) at $149/month. Foundayo is the direct-to-consumer cash-pay brand and does not bill insurance; NYRx PDL status is irrelevant to the Foundayo pathway.
• GoodRx and other discount-card programs. For T2D-indicated GLP-1s (Ozempic, Trulicity, Victoza), GoodRx coupons are a cash-pay fallback when NYRx PA is not the right pathway. Pricing varies by zip code and pharmacy.
• Compounded options. Compounded semaglutide and compounded tirzepatide from licensed 503A pharmacies run roughly $99–$300/month in the cash-pay market. Important regulatory caveat: the FDA enforcement- discretion period for compounded tirzepatide ended October 2024, and for compounded semaglutide ended February 2025. Compounding activity for these molecules is in a regulatory grey zone. The article does not name specific compounding pharmacies or telehealth vendors. Patients considering compounded options should verify the pharmacy's NPI, state board licensure, and product-quality testing before ordering.

For more on the manufacturer-direct cash-pay landscape and the relationship between insurance pathways and self-pay options, see our GLP-1 insurance coverage across Medicare, Medicaid, and commercial deep-dive.

Bottom line

New York Medicaid — the fourth-largest US Medicaid program at ~7M enrollees — has the strongest-evidenced weight-loss-drug exclusion in our 50-state Medicaid series so far. The exclusion is triple-anchored: by federal statute (42 U.S.C. § 1396r-8(d)(2)(A)), by NY state regulation (18 NYCRR § 505.3(g)(3)), and by explicit drug-brand-named NYRx contractor documentation that names Ozempic, Wegovy, and Mounjaro as “excluded from coverage for weight loss indications.”

Ozempic, Trulicity, Victoza (BLTG-Preferred), and exenatide are Preferred GLP-1s for type 2 diabetes on the April 23, 2026 NYRx PDL. Mounjaro, Rybelsus, Bydureon BCise, liraglutide-generic, Soliqua, and Xultophy are Non-Preferred for T2D (PA required). Class Clinical Criteria require confirmation of an FDA-approved or compendia-supported Medicaid-covered indication and PA when used concurrently with a DPP-IV inhibitor.

Wegovy is covered ONLY for the FDA-approved MACE- reduction indication via a separate Drug Utilization Review (DUR) entry, and the NYRx PA criteria are STRICTER than the FDA Wegovy MACE label: BMI ≥ 40 kg/m² (FDA label allows ≥ 27 with established CVD), six months of documented adherence to cardiovascular therapy (antihypertensive + lipid-lowering + anti-thrombotic), six months of comprehensive lifestyle modifications, AND a LIFETIME LIMIT OF TWO TREATMENT ATTEMPTS. The 11-question NYRx Wegovy PA Form (Rev. 10/30/25) operationalizes these criteria.

Wegovy for chronic weight management (no CV diagnosis), Zepbound, Saxenda, and Foundayo are NOT covered by NYRx. No PA pathway exists for any of these drugs in any verified primary source as of the April 23, 2026 NYRx PDL revision.

Imcivree (setmelanotide) is the only obesity-indicated drug with a published NYRx PA pathway, for the small clinical population with confirmed monogenic / syndromic genetic obesity (POMC, PCSK1, LEPR deficiency or Bardet-Biedl syndrome).

NYRx imposes anti-stockpiling rules unique among large-state Medicaid programs: no concurrent GLP-1 fills; the 25%-of-current-fill rule blocks dose titration and mid-cycle switching unless a separate PA from the Clinical Call Center is approved; pharmacies receive rejections at point of sale when the rules are violated.

Effective April 1, 2023, NYS carved the entire outpatient pharmacy benefit out of mainstream Managed Care into NYRx, the statewide fee-for-service pharmacy program. Plan-level GLP-1 PA divergence across Healthfirst, MetroPlusHealth, Fidelis Care, EmblemHealth, MVP, and Excellus is structurally impossible for mainstream MMC, HARP, and HIV-SNP enrollees. Members in MLTC, PACE, MAP, the Essential Plan, and Child Health Plus are NOT subject to NYRx and the rules in this article do not directly apply.

KFF's January 2026 tracker lists New York among the 13 states “covering GLP-1s for obesity treatment under fee-for-service.” That classification is anchored solely to the narrow Wegovy MACE pathway gated by BMI ≥ 40 + established CVD + 6 months of CVD therapy + lifestyle modifications + lifetime cap of 2 attempts. New York does NOT cover Wegovy or any other GLP-1 for the chronic-weight-management indication absent established cardiovascular disease.

Three pending NY 2025-2026 Session bills (Assembly A09360, Senate S5798, Assembly A2715 / Senate S3104) would mandate NYRx coverage of FDA-approved GLP-1s for chronic weight management. All four remain in committee; none has been enacted.

Members denied a GLP-1 PA may request a Fair Hearing through the New York State Office of Temporary and Disability Assistance within the time window stated on their Notice of Action; for adjudication-error appeals (BMI / CVD-therapy / lifestyle documentation issues, anti-stockpiling 25%-rule miscalculation, Imcivree genetic-confirmation issues), the Fair Hearing is the appropriate escalation pathway. Policy- level determinations (the weight-loss exclusion itself) are not appealable through a Fair Hearing.

The article makes no clinical recommendation, no plan- specific coverage promise, and no PA-success guarantee. Coverage and PA outcomes vary by individual clinical facts and the current PDL revision. PDL status is as of the April 23, 2026 NYRx revision; updates are published periodically and PDL status is subject to change. Readers should call the NYRx Education & Outreach Call Center at 1-833-967-7310 (M-F 8 AM - 5 PM ET) or the NYRx Clinical Call Center at 1-877-309-9493 (24/7) for an authoritative determination on any specific case.

Related research

• Ohio Medicaid GLP-1 coverage (2026): triple-anchored exclusion + the January 2026 Wegovy MACE/MASH carve-back-in — New York's closest structural twin in the five-state series. Both are triple-anchored (federal + state regulation + state- PBM operational notice). Key differences: Ohio MACE BMI threshold = 27 (NY = 40, NY is stricter on BMI floor); Ohio explicitly excludes patients with T1D or T2D from the MACE pathway, A1C < 6.5% required (NY does not impose this diabetes exclusion); Ohio has a Wegovy MASH pathway as of January 7, 2026 (NY does not, as of April 23, 2026 NYRx PDL); Ohio has no lifetime treatment-attempt limit (NY caps at 2 lifetime attempts); Ohio uses a real-time Gainwell claim gate (NY uses a provider-facing policy document). Both Gainwell SPBM (Ohio) and NYRx (Prime Therapeutics) make plan-level divergence structurally impossible.
• Florida Medicaid GLP-1 coverage (2026): the silent exclusion — companion 50-state Medicaid series article. Florida is the weakest-evidenced explicit exclusion in the four-state cluster and the sharpest contrast to New York's triple-anchored exclusion. New York's weight-loss ban is anchored by federal statute, state regulation (18 NYCRR § 505.3(g)(3)), AND explicit drug-brand-named NYRx contractor documentation naming Ozempic / Wegovy / Mounjaro directly. Florida has none of these: no state-regulation hook, no explicit non-coverage notice, and no contractor language — only the operational silence of the AHCA PDL, the March 12, 2026 GLP-1 Criteria PDF, and the April 30, 2026 Drug Limitations document. New York also covers Wegovy via a narrow MACE pathway (BMI ≥ 40, established CVD, 6-month CVD-therapy adherence, lifetime cap of 2 attempts); Florida has no equivalent coverage pathway for any weight-management indication.
• California Medi-Cal GLP-1 coverage (2026): the state reversal that removed Wegovy + Zepbound for weight loss — companion 50-state Medicaid series article. The most structurally similar state to New York: both have centralized statewide pharmacy carve-outs (Medi-Cal Rx Jan 1, 2022; NYRx April 1, 2023). California previously covered weight-management GLP-1s and reversed effective January 1, 2026 via the enacted state budget; NY's exclusion has been continuous and is more layered (triple- anchored vs CA's budget-instrument plus federal- statute pairing).
• Texas Medicaid GLP-1 coverage + STAR+PLUS PA pathway (2026) — companion 50-state Medicaid series anchor. Texas has plan-level managed-care discretion through STAR+PLUS (Aetna Better Health, Wellpoint, Molina, Superior HealthPlan, UnitedHealthcare Community Plan) operating under the state VDP PDL; NY's NYRx carve-out is a structurally different system that consolidates all mainstream MMC pharmacy PA into a single statewide PBM. Both states use the federal optional weight-loss-drug exclusion at 42 USC § 1396r-8(d)(2)(A).
• GLP-1 insurance coverage across Medicare, Medicaid, and commercial — the federal-state coverage framework, KFF state tracker, and how Wegovy / Zepbound / Foundayo actually flow through Medicare Part D and state Medicaid programs. NYRx's Wegovy MACE pathway is an example of a state-Medicaid covered non-weight-loss indication; the same Wegovy CV indication is also Part D-coverable for dual-eligibles.
• GLP-1 insurance dropped coverage appeal playbook — the four-phase appeal logic that applies directly to NYRx PA denials, with the OTDA Fair Hearing substituted for the commercial-plan internal-appeal pathway.
• Cigna GLP-1 prior-authorization guide — verbatim IP0206 / CNF 684 / CNF 360 coverage policies for Cigna's commercial-plan analog (and Cigna's NY-region Medicare Advantage plans).
• Aetna GLP-1 prior-authorization guide — verbatim 4774-C / 6947-C / 1227-C coverage policies for Aetna's commercial-plan analog.
• Wegovy alternatives 2026 — for NY Medicaid members whose Wegovy MACE-pathway PA was denied (BMI < 40, no CVD, lifetime-cap exhaustion) and who are evaluating Zepbound, Foundayo, Saxenda, and the cash-pay landscape.
• Zepbound alternatives 2026 — formulary-displaced patient profiles and the realistic alternatives when Zepbound is unavailable. NY Medicaid does not cover Zepbound under any indication on the April 23, 2026 NYRx PDL.
• GLP-1 prior-authorization letter generator — embeds verbatim payer-policy criteria into a Letter of Medical Necessity template usable for NYRx PA submissions and OTDA Fair Hearing requests.