Tennessee Medicaid (TennCare) GLP-1 Coverage (2026): Pattern #13 — Positive-Coverage Expansion From Prior Categorical-Exclusion Baseline (Sequence 10-34-25 + 2025 Public Chapter 530 + Aug 1, 2025 Emergency Rule) — Wegovy + Zepbound Preferred, 5-Indication PA Form, Broadest No-PA AOM Panel in Series, Uniform Statewide MCO Carve-Out

TL;DR

Tennessee Medicaid (TennCare) covers GLP-1 receptor agonists for chronic weight management effective August 1, 2025. As of the TennCare Preferred Drug List effective May 1, 2026, Wegovy and Zepbound are PREFERRED drugs (PA + quantity limit 4 injections/month) in a dedicated “GLP-1 Weight Management Agents” class. Saxenda and generic liraglutide (weight management) are Non-Preferred (PA + QL; step-therapy through two preferred agents required).

This coverage was not in place before August 1, 2025. TennCare was a categorical-exclusion state for the entirety of its prior existence. The expansion is anchored in two primary sources: (1) Sequence Number 10-34-25, the formal rulemaking filing that amended four separate rule provisions (Rules 1200-13-13-.04, 1200-13-13-.10, 1200-13-14-.04, and 1200-13-14-.10) to add “except for weight loss drugs when prescribed for treatment of obesity” to each, effective January 26, 2026; and (2) the August 1, 2025 OptumRx Provider Notice confirming the same coverage started on an emergency-rule basis that same date. Funding was appropriated in 2025 Public Chapter No. 530 (HB1409, the FY2025-2026 Tennessee Appropriations Act), with the Bureau of TennCare projecting approximately $2.7 million in annual expenditure increase.

The GLP-1 PA Form (revision date 04/2026) includes a five-indication selector: Type 2 Diabetes, Obesity Management Therapy, CV Risk Reduction, Obstructive Sleep Apnea, and NASH/MASH — the broadest indication-selector verified on any state Medicaid GLP-1 PA form in this 13-state series. Separate PA criteria govern each indication on the same form, so Wegovy can be approved for obesity, MACE, or MASH under different criteria; Zepbound can be approved for obesity or OSA.

All four TennCare MCOs — Wellpoint Tennessee (formerly Amerigroup), BlueCare (operated by Volunteer State Health Plan / BCBSTN), UnitedHealthcare Community Plan of Tennessee, and TennCare Select — defer pharmacy benefits to a unified statewide carve-out administered by OptumRx. There is no MCO-specific formulary to check; the same PDL applies to every TennCare enrollee regardless of regional MCO assignment.

Critical asymmetry: The State of Tennessee Group Insurance Program (state employee plan, Caremark-administered) covers Wegovy with PA but does NOT cover Zepbound for weight loss as of the 10/01/2025 formulary. TennCare Medicaid covers both. A state employee with Medicaid eligibility (an uncommon edge case) would follow the TennCare pathway, not the state employee plan. The two programs have different PBMs, different formularies, and different PA processes.

Initial PA approval duration is 1 year. (A December 1, 2025 provider notice had announced a 3-month initial window, but that proposal was reversed by the January 1, 2026 provider notice “in effort to reduce PA burden on providers and members.”) Renewal requires documented weight loss of ≥ 5% of baseline body weight.

KFF (January 2026) classifies Tennessee as one of 13 state Medicaid programs covering GLP-1s for obesity under fee-for-service, and as one of three states (with Missouri and Utah) that added coverage in the August 2024 → January 2026 reporting interval — the opposite policy direction from Pennsylvania and South Carolina, which eliminated coverage in the same period.

Pattern #13 in the 50-state taxonomy: positive-coverage expansion from a regulatory-explicit exclusion baseline

Tennessee is the first state in this 13-state series whose article reports a positive-coverage expansion from a prior regulatory-explicit exclusion baseline. That distinction is worth unpacking precisely, because Tennessee is sometimes grouped with North Carolina (Anchor #9) as both being “positive-coverage states” — but the two patterns are structurally different.

North Carolina (Anchor #9) was a double-reversal state: NC had continuous GLP-1 obesity coverage since August 1, 2024, briefly terminated it for 73 days due to a budget stalemate (October 1 → December 12, 2025), and reinstated it by gubernatorial directive in December 2025. NC’s coverage authority throughout was the same SPA (TN 24-0032); the termination-and-reinstatement was an operational interruption within an ongoing coverage framework.

Tennessee’s pattern is different: TennCare was a categorical-exclusion state for the entirety of TennCare’s existence prior to August 1, 2025. The exclusion was anchored in Rule 1200-13-13-.10(3)(a)(14)(i) (TennCare Medicaid) and Rule 1200-13-14-.10(3)(a)(14)(i) (TennCare Standard), both of which excluded “Agents when used for anorexia or weight loss.” This language paralleled the categorical exclusions in New York (18 NYCRR § 505.3(g)(3)), Illinois (89 IAC § 140.441(b)), New Jersey (N.J.A.C. 10:51-1.13(a)(2)), and Arizona (AHCCCS FFS Provider Billing Manual Chapter 12, item #13). Tennessee chose to invoke the federal optional-exclusion authority at 42 U.S.C. § 1396r-8(d)(2)(A) — which permits states to exclude “Agents when used for anorexia, weight loss, or weight gain” — and did so continuously.

The 2025–2026 Sequence 10-34-25 rule amendment did not repeal that invocation. It added a five-word carve-out: “except for weight loss drugs when prescribed for treatment of obesity” to all four rule provisions. Tennessee still invokes the federal exclusion authority for non-obesity weight-loss indications; it exempts FDA-approved obesity-treatment indications from that invocation. The 2025 amendment is therefore a regulatory carve-back-IN, not a wholesale elimination of the exclusion framework.

Within the 13-state series, TN’s taxonomy position is distinct from every other anchor:

Coverage status as of May 10, 2026. Source: primary-source PDL and PA-criteria verification for each state. See the individual state articles for full documentation.

The August 1, 2025 expansion: PC 530, Sequence 10-34-25, and the four-rule amendment

TennCare’s coverage of GLP-1 receptor agonists for obesity did not arise from a standalone obesity-drug legislation. It arose from an administrative-regulatory sequence initiated by the Bureau of TennCare:

1. FY2025-2026 Appropriations Act (2025 Public Chapter No. 530, HB1409 / SB1431) — signed into law by the Tennessee General Assembly. The act funded TennCare Medical Services at $9,634,112,600. It did not include any substantive obesity-coverage policy language (verified by direct grep of 8,807-line extracted text: zero occurrences of “obesity,” “weight,” “GLP,” “Wegovy,” or “Zepbound” as policy directives). PC 530 is the funding anchor, not the policy anchor.
2. Emergency rule filed and effective August 1, 2025— The Bureau of TennCare filed an emergency rule adding the five-word carve-out phrase to four separate TennCare rule provisions. On the same date, OptumRx issued the “Obesity Management Agents 08-01-25” provider notice confirming operational coverage start for both adults (ages 21 and over) and children per medication label.
3. Notice of Rulemaking Hearing filed July 14, 2025; rulemaking hearing conducted September 4, 2025.
4. Director’s signature October 16, 2025 (Stephen Smith, Director, Division of TennCare); filed with the Tennessee Department of State October 28, 2025.
5. Permanent rule effective January 26, 2026 — Sequence Number 10-34-25, Rule IDs 10445–10446, confirmed the same coverage permanently in the formal rule body.

The procedural history is verbatim from the filing form:

“Sequence Number: 10-34-25 / Rule ID(s): 10445-10446 / File Date: 10/28/2025 / Effective Date: 1/26/2026 / Content based on previous emergency rule filed on 08/01/2025 / Notice of Rulemaking Hearing filed with the Department of State on: 07/14/2025 / Rulemaking Hearing(s) Conducted on: 09/04/2025”

The August 1, 2025 date is the operational coverage start; the January 26, 2026 date is the formal-rule-codification. Both are correct primary-source dates. Article readers who see either date in a provider communication are seeing the same underlying coverage expansion.

The four-rule amendment — verbatim

Sequence 10-34-25 amends FOUR separate rule provisions. Each addition is the same five words: “except for weight loss drugs when prescribed for treatment of obesity.” Verbatim from the filing:

“Part 1 of Subparagraph (c) of Paragraph (1) of Rule 1200-13-13-.04 Covered Services is amended by adding the comma and phrase ‘, except for weight loss drugs when prescribed for treatment of obesity’ to the end of the part so that as amended Part 1 shall read as follows: 1. Agents for weight loss or weight gain, except for weight loss drugs when prescribed for treatment of obesity.”

“Subpart (i) of Part 14 of Subparagraph (a) of Paragraph (3) of Rule 1200-13-13-.10 Exclusions is amended by adding the comma and phrase ‘, except for weight loss drugs when prescribed for treatment of obesity’ to the end of the subpart so that as amended Subpart (i) shall read as follows: (i) Agents when used for anorexia or weight loss, except for weight loss drugs when prescribed for treatment of obesity”

“Part 1 of Subparagraph (c) of Paragraph (1) of Rule 1200-13-14-.04 Covered Services is amended by adding the comma and phrase ‘, except for weight loss drugs when prescribed for treatment of obesity’ to the end of the part so that as amended Part 1 shall read as follows: 1. Agents for weight loss or weight gain, except for weight loss drugs when prescribed for treatment of obesity.”

“Subpart (i) of Part 14 of Subparagraph (a) of Paragraph (3) of Rule 1200-13-14-.10 Exclusions is amended by adding the comma and phrase ‘, except for weight loss drugs when prescribed for treatment of obesity’ to the end of the subpart so that as amended Subpart (i) shall read as follows: (i) Agents when used for anorexia or weight loss, except for weight loss drugs when prescribed for treatment of obesity”

Each amended provision cites the same statutory authority: “T.C.A §§ 4-5-202, 4-5-203, 71-5-102, 71-5-105, 71-5-107, 71-5-109, and 71-5-134; 2025 Public Chapter No. 530.”

Fiscal note

Verbatim from the Sequence 10-34-25 filing (lines 254–257):

“The promulgation of these rules is anticipated to increase annual TennCare Medicaid and TennCare Standard expenditures by approximately $2,700,000. Funding for these expenditures was appropriated by the Tennessee General Assembly in the 2025 Appropriations Act.”

This $2.7 million annual-expenditure projection is substantially smaller than NJ DMAHS’s published $170.8 million state-fund-net projection for full NJ FamilyCare coverage extension or Pennsylvania’s retrospective $836 million total-funds-savings estimate for its termination decision. The article cannot predict whether TennCare’s actual costs will match or exceed the $2.7 million projection; the record as of May 10, 2026 is that funding was appropriated for the FY2025-2026 cycle and the rule is operationally in force.

Public comment record

Verbatim from the filing (lines 187–191):

“TennCare received one comment concerning these rule amendments. This commenter expressed support for the provision of the rule providing for coverage by TennCare of weight loss drugs when prescribed for treatment of obesity on the basis that covering medications for treatment of obesity will improve the health of TennCare enrollees and help avoid the development of costly co-morbid conditions. TennCare thanks the commenter for their support. No changes were made to the rule based on this comment.”

The regulatory record was uncontested: one supportive comment, zero opposing comments.

The 2022 Chronic Weight Management Task Force: the policy precursor

The 2025–2026 expansion was not a sudden reversal. It was the operational fulfillment of a recommendation made three years earlier.

The Tennessee 112th General Assembly established the Chronic Weight Management Task Force in 2022. Co-chairs were Senator Shane Reeves, PharmD (Senate chair) and Representative Sabi Kumar, MD (House chair). The final report was published September 2022 with the title “Recommendations for addressing the obesity and diabetes epidemic in Tennessee.”

Verbatim Recommendation 2 from the task force final report (lines 143–150):

“2. Anti-Obesity Medication coverage for all TennCare enrollees who qualify and meet medical [necessity criteria]: a. TennCare provides access to anti-obesity medications for enrollees under the age of 21. The Task Force recognizes and appreciates this treatment option that TennCare makes [available]; … [the Task Force] recommends that TennCare provide coverage of anti-obesity medications to all enrollees who qualify and meet specified TennCare medical criteria.”

The pre-2025 baseline was EPSDT-anchored pediatric coverage: TennCare already covered anti-obesity medications for enrollees under 21 through the federal Early and Periodic Screening, Diagnostic, and Treatment mandate. The task force’s Recommendation 2 targeted the gap between that pediatric coverage and coverage for adult enrollees who also qualified for anti-obesity medication. The August 1, 2025 amendment is, verbatim, the operational answer to that recommendation — “all enrollees who qualify and meet specified TennCare medical criteria” rather than only those under 21.

The co-chair credentials are notable: a PharmD (Senator Reeves) and an MD (Representative Kumar) co-led the task force. The 2022 report represents clinical and legislative expertise applied to TennCare policy three years before the recommendation was acted upon. The task force also recommended aligning TennCare’s bariatric surgery coverage with ASMBS guidelines for adolescents (Recommendation 4) — TennCare does cover bariatric surgery for adults 18 and over, consistent with both recommendations.

The dedicated “GLP-1 Weight Management Agents” PDL subclass

Tennessee is the only state in this 13-state series whose statewide Medicaid PDL has a dedicated “GLP-1 Weight Management Agents” formulary subclass entirely separate from the GLP-1 Agonists (T2D) class. Verbatim from the TennCare PDL effective May 1, 2026 (Page 71 of 81):

“*WEIGHT MANAGEMENT AGENTS* … *GLP-1 Weight Management Agents* / Preferred Drugs: Wegovy® injection PA, QL    Zepbound® autoinjector PA, QL / Non-Preferred Drugs: liraglutide (weight management) injection PA, QL    Saxenda® injection PA, QL”

The full WEIGHT MANAGEMENT AGENTS section of the PDL includes four subclasses: Appetite and Absorption Agents, GLP-1 Weight Management Agents, Neurobehavioral Appetite Modulators, and Obesity Agents for Rare Disorders. Wegovy and Zepbound also appear in the GLP-1 Agonists (T2D) class (Page 50) as preferred with PA and QL. They are listed in both classes because they are FDA-approved for multiple indications; the PA form’s indication selector determines which set of criteria applies to each prescription.

Mounjaro (tirzepatide T2D indication) is Non-Preferred in the T2D class and does NOT appear in the GLP-1 Weight Management Agents class. The weight-management tirzepatide formulation is Zepbound (FDA-approved for obesity). TennCare does not cover Mounjaro for weight management. These are two separate FDA-approved products sharing an active ingredient; they cannot be substituted for each other under TennCare PA criteria.

All 10 traditional AOMs covered without PA: the broadest no-PA panel in the series

The Appetite and Absorption Agents subclass of the TennCare PDL lists ten traditional anti-obesity medications as Preferred with quantity limit only — NO prior authorization required. This is the broadest no-PA AOM panel verified in any state Medicaid PDL in this 13-state series. Verbatim from the PDL (Page 71 of 81):

“*Appetite and Absorption Agents* … Preferred Drugs: benzphetamine tabs QL  / diethylpropion tabs QL  / diethylpropion ER tabs QL  / Lomaira® tabs QL  / orlistat caps QL  / phendimetrazine IR tabs QL  / phendimetrazine ER caps QL  / phentermine caps, tabs QL  / phentermine/topiramate caps QL  / Xenical® caps QL”

The August 1, 2025 provider notice confirmed the same list at launch:

“The following will be considered preferred without PA: benzphetamine QL, diethylpropion QL, LOMAIRA QL, ORLISTAT QL, phendimetrazine QL, phentermine QL, phentermine/topiramate QL.”

The January 1, 2026 provider notice added Xenical, diethylpropion CR, phendimetrazine IR, and phendimetrazine ER to the Preferred list, expanding the no-PA AOM panel to its current ten entries. No state in the prior 12-anchor analysis covers this many traditional AOMs as Preferred without PA.

Wegovy obesity PA criteria (verbatim)

Verbatim from the TennCare Clinical Criteria document, effective May 1, 2026 (Page 500), for the Weight Management Agents PA Form:

“Wegovy® Injection Initial PA Criteria: • Patient must be the labeled age minimum (Wegovy ≥ 12); AND • Treatment is for the management of obesity; AND • One of the following: [for patients < 18 years of age, submission of medical records documenting the BMI is ≥ 95th percentile standardized for age and sex; OR for patients ≥ 18 years of age, one of the following: submission of medical records documenting a body mass index (BMI) > 30 kg/m²; OR submission of medical records documenting a BMI of greater than 27 kg/m² with a weight related comorbidity (e.g. hypertension, dyslipidemia, diabetes, coronary heart disease, MASH/NASH, obstructive sleep apnea)]; AND • Prescriber attests patient is participating in complementary nutritional and lifestyle changes (e.g., dietary modification, increased physical activity as medically able, structured behavioral intervention, comprehensive weight management program); AND • Medication will not be used in combination with other medications FDA approved for obesity/weight loss; AND • Will not be co-administered with another GLP-1 receptor agonist; AND • Patient does not have personal or immediate family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2) Wegovy® Injection Renewal PA Criteria: • Patient has continued participating in complementary nutritional and lifestyle changes … • Medication will not be used in combination with other medications for obesity/weight loss; AND • Submission of medical records (e.g., chart notes) documenting a weight loss of ≥ 5% of baseline body weight”

Key features:

• No metformin or other drug step-therapy required before GLP-1 approval for obesity management.
• FDA-label-aligned BMI thresholds: BMI > 30 OR BMI > 27 with comorbidity. TennCare does NOT impose the BMI ≥ 40 floor Michigan uses for general weight management, or the BMI ≥ 35 floor Michigan uses for Zepbound OSA. The thresholds match the FDA-approved indications verbatim.
• Pediatric coverage extends to age ≥ 12 for Wegovy (FDA-labeled minimum), using BMI ≥ 95th percentile standardized for age and sex.
• 1-year initial PA duration, with one additional month available at renewal failure to allow for titration off medication.
• Renewal threshold: ≥ 5% of baseline body weight(verbatim; not “5% weight loss” in isolation — the percentage is measured against the documented baseline).

Zepbound obesity PA criteria (verbatim)

Verbatim from the Clinical Criteria document, effective May 1, 2026 (Page 501):

“Zepbound® Injection Initial PA Criteria: • Patient must be the labeled age minimum (Zepbound ≥ 18); AND • Treatment is for the management of obesity; AND • One of the following: [submission of medical records documenting a body mass index (BMI) > 30 kg/m²; OR submission of medical records documenting a BMI of greater than 27 kg/m² with a weight related comorbidity …]; AND • Prescriber attests patient is participating in complementary nutritional and lifestyle changes …; AND • Medication will not be used in combination with other medications FDA approved for obesity/weight loss; AND • Will not be co-administered with another GLP-1 receptor agonist; AND • Patient does not have personal or immediate family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2) Zepbound® Injection Renewal PA Criteria: • Submission of medical records (e.g., chart notes) documenting a weight loss of ≥ 5% of baseline body weight”

Zepbound is restricted to enrollees age ≥ 18 by FDA label; adolescents 12–17 are eligible for Wegovy, Saxenda, and generic liraglutide (weight management) but not Zepbound. TennCare’s PA criteria enforce the labeled-age-minimum requirement for each agent.

The five-indication GLP-1 PA Form: broadest indication-selector in the series

The TennCare GLP-1 Agonists PA Form (revision date 04/2026) includes a single indication-selector covering five FDA-approved GLP-1 indications. Verbatim from page 2 of the form:

“CLINICAL CRITERIA / NOTE: Submission of medical records confirming diagnosis is required. Failure to provide the requested documentation will delay response. / Complete Questions 1-7 for ALL requests. / 1. What is the diagnosis the requested agent is being used for? ☐ Type 2 Diabetes / ☐ Obesity Management Therapy / ☐ CV Risk Reduction / ☐ Obstructive Sleep Apnea / ☐ NASH/MASH / ☐ Other:”

This is the most expansive indication-selector on any state Medicaid GLP-1 PA form in the 50-state series verified to date. A prescriber submits a single form, checks the applicable indication box, and the criteria that follow depend on that selection. The five indications are:

1. Type 2 Diabetes — preferred: Ozempic, Victoza, Wegovy, Zepbound; non-preferred: Mounjaro, Rybelsus, Trulicity, Soliqua, Xultophy, exenatide, liraglutide generics. No metformin step-therapy required.
2. Obesity Management Therapy — preferred: Wegovy, Zepbound; non-preferred: Saxenda, liraglutide (weight management) after trial-and-failure of two preferred agents. BMI > 30 or BMI > 27 + comorbidity.
3. CV Risk Reduction — Wegovy only (FDA MACE indication). See § below.
4. Obstructive Sleep Apnea — Zepbound only (FDA OSA indication). See § below.
5. NASH/MASH — Wegovy only (FDA noncirrhotic MASH indication). See § below.

Wegovy MACE pathway: CV risk reduction PA criteria (verbatim)

Verbatim from the Clinical Criteria document (Page 292), GLP-1 Agonist PA Form, CV Risk Reduction due to prior MI, prior stroke, or peripheral arterial disease:

“Wegovy® injection Initial PA Criteria: • Treatment is being requested to reduce the risk of major adverse cardiovascular events; AND • Patient is 18 years of age or older; AND • Submitted medical documentation (e.g. chart notes) of initial BMI ≥ 27 kg/m²; AND • Submitted medical documentation (e.g. chart notes) of ONE of the following: [Prior myocardial infarction / Prior stroke (ischemic and hemorrhagic stroke) / Symptomatic peripheral arterial disease as evidenced by intermittent claudication with ankle–brachial index < 0.85, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease]; AND • Patient is on optimized guideline-directed therapy including beta-blockers, RAS inhibitors, and lipid lowering agents to ensure reduced cardiovascular risk unless contraindicated (supported by medical documentation or claims history); AND • Prescriber attests patient is participating in complementary nutritional and lifestyle changes … • Will not be used concomitantly with DPP-4 inhibitors; AND • Will not be co-administered with another GLP-1 receptor agonists”

TennCare’s MACE pathway uses BMI ≥ 27 — directly FDA-label-aligned (the MACE indication in the Wegovy prescribing information). This is more permissive than New York’s BMI ≥ 40 floor for its DUR cardiovascular pathway. TennCare does not impose a diabetes diagnosis requirement, no lifetime-attempt cap, and no specialist referral requirement for the MACE indication.

Wegovy noncirrhotic NASH/MASH pathway (verbatim)

Verbatim from the Clinical Criteria document (Pages 292–293):

“Noncirrhotic nonalcoholic steatohepatitis (NASH) or Metabolic dysfunction associated steatohepatitis (MASH): Wegovy® injection Initial PA Criteria: • Patient is greater than or equal to 18 years of age; AND • Diagnosis of NASH or MASH; AND • Submission of medical records (e.g. chart notes) confirming disease is fibrosis stage F2 or F3 as confirmed by ONE of the following: [FibroScan / Fibrosis-4 index (FIB-4) / Magnetic Resonance Elastography (MRE) / Liver Biopsy]; AND • Prescriber attests patient is participating in a supervised comprehensive weight management program …; AND • Prescribed by or in consultation with a gastroenterologist or hepatologist; AND • Will not be used concomitantly with DPP-4 inhibitors; AND • Will not be co-administered with another GLP-1 receptor agonists; AND • Patients does not have personal or immediate family history of medullary thyroid carcinoma or MEN2”

Fibrosis stage F2 or F3 is required (TennCare does NOT cover stage F1 for MASH). North Carolina’s MASH criteria cover F1/F2/F3 — broader than TennCare for this indication. TennCare requires a gastroenterologist or hepatologist to prescribe or consult.

Zepbound moderate-to-severe OSA pathway (verbatim)

Verbatim from the Clinical Criteria document (Page 293):

“Obstructive Sleep Apnea: Zepbound® injection Initial PA Criteria: • Patient is 18 years of age or older; AND • Diagnosis of moderate to severe Obstructive Sleep Apnea (OSA); AND • Hypersomnolence secondary to another sleep disorder, neurologic disorder, medical condition, or by medicine or substance use has been ruled out; AND • Submission of medical records (e.g. chart notes) documenting BOTH of the following: [Initial BMI ≥ 30 kg/m²; AND ≥ 15 respiratory events per hour of sleep confirmed by sleep study]; AND • Prescriber attests patient is participating in complementary nutritional and lifestyle changes …; AND • Trial and failure (minimum duration 3 months with documented compliance) of Continuous Positive Airway Pressure (CPAP) or BiPAP device, unless contraindicated; AND • Will not be used concomitantly with DPP-4 inhibitors; AND • Will not being co-administered with another GLP-1 receptor agonists; AND • Patients does not have personal or immediate family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2)”

TennCare’s OSA BMI floor is BMI ≥ 30— FDA-label-aligned. This is more permissive than Pennsylvania’s BMI ≥ 35 OSA floor. The CPAP/BiPAP trial-and-failure requirement (minimum 3 months with documented compliance, unless contraindicated) is structurally consistent with the FDA label population from the SURMOUNT-OSA trials.

Statewide MCO carve-out: why your MCO assignment does not affect GLP-1 coverage

TennCare operates a statewide pharmacy carve-out through OptumRx. Unlike most state Medicaid programs where MCOs individually administer pharmacy benefits (with varying PDLs, PA criteria, and coverage decisions), TennCare’s pharmacy benefit is contracted directly to OptumRx by the Bureau of TennCare. All four MCOs defer pharmacy benefits to this unified statewide carve-out.

The four TennCare MCOs, verbatim from the TennCare MCOs web page:

“1. Wellpoint (formerly Amerigroup) / 2. BlueCare (operated by Volunteer State Health Plan, a wholly-owned subsidiary of BlueCross BlueShield of Tennessee) / 3. UnitedHealthcare Community Plan / 4. TennCare Select”

A TennCare enrollee in Memphis (West Tennessee, assigned to Wellpoint), Nashville (Middle Tennessee, assigned to BlueCare), or Knoxville (East Tennessee, assigned to UHC) is on the same TennCare PDL, the same OptumRx PA criteria, and the same GLP-1 Weight Management Agents coverage rules. TennCare Select (covering children in state custody and CHOICES long-term-services-and-supports members) is also on the same statewide carve-out.

This is structurally distinct from:

• Texas (#1): Six MCOs each with MCO-specific formularies layered on top of the Acentra VDP statewide non-coverage PDL.
• New Jersey (#11): Five MCOs (Aetna, Fidelis, Horizon, UHC, Wellpoint) each with contract-specific clinical criteria under the DMAHS PDL exclusion.
• Georgia (#8): Six CMOs (Amerigroup, CareSource, Peach State, Wellcare, etc.) each with parallel exclusion language.

For a TennCare enrollee, the applicable action is not to “ask your MCO about coverage.” Coverage is determined by the statewide TennCare PDL and OptumRx clinical criteria. PA requests go to OptumRx using the Weight Management Agents PA Form (for chronic weight management) or the GLP-1 Agonist PA Form (for T2D, MACE, MASH, OSA). Pharmacy claims route to BIN 001553 / PCN TNM.

Note: BCBSTN’s commercial and Medicare Advantage products use different formularies. BlueCare Plus 2026 Medicare Advantage (D-SNP) is a Medicare product, not a Medicaid product, and is governed by different coverage rules. TennCare members should not reference commercial or Medicare Advantage BCBSTN documents for Medicaid coverage guidance.

State employee plan asymmetry: TennCare covers Zepbound; the State of Tennessee Group Insurance Program does not

Tennessee presents the second cross-jurisdictional coverage asymmetry in this 13-state series (the first was New Jersey, where SHBP state-employee coverage runs opposite to NJ FamilyCare Medicaid exclusion). Tennessee’s asymmetry runs the opposite direction from North Carolina.

Verbatim from the State of Tennessee Performance Drug List (Standard Control / Advanced Control Specialty), effective 10/01/2025, Caremark/CVS-administered (the state employee plan formulary), Page 18:

“ANTI-OBESITY AGENTS / liraglutide (weight management) sopn 6mg/ml / Genericdrug  1  PA; Weight Loss Coinsurance Applies / … SAXENDA SOPN 18MG/3ML / Branddrug  2  PA; Weight Loss Coinsurance Applies / WEGOVY SOAJ .25MG/0.5ML, .5MG/0.5ML, 1MG/0.5ML, 1.7MG/0.75ML, 2.4MG/0.75ML / Branddrug  2  PA; Weight Loss Coinsurance Applies”

Zepbound does not appear. The state employee plan formulary was searched exhaustively: zero occurrences of “ZEPBOUND” or “tirzepatide” as of 10/01/2025.

The coverage comparison:

TennCare PDL verified effective May 1, 2026. State employee plan formulary verified effective 10/01/2025. Both subject to revision; check the applicable formulary for current status.

This is the inverse of North Carolina’s asymmetry: NC Medicaid covers GLP-1s for chronic weight management (Wegovy Preferred since December 2025 reinstatement) while the NC State Health Plan (SHP) for state employees terminated coverage in April 2024 and remains off. In Tennessee, TennCare Medicaid covers Zepbound while the State of Tennessee Group Insurance Program does not.

A TennCare enrollee should NOT consult a state employee benefits document for guidance on TennCare coverage. The two plans are administered by different PBMs and have separate formularies, eligibility rules, and PA processes.

December 1, 2025 DUR hard edit and the January 1, 2026 PA-duration reversal

DUR hard edit effective December 12, 2025

Verbatim from the December 1, 2025 OptumRx provider notice:

“GLP-1 RECEPTOR AGONISTS: Effective December 12, 2025, all GLP-1 Receptor agonists will be subject to a DUR hard edit to prevent overutilization, fraud, waste, and abuse. Following implementation of this hard DUR edit, members may only fill one GLP-1 Receptor Agonist agent at a time. Members may refill a GLP-1 receptor agonist after meeting the 85% refill threshold, including when changing between products or strengths. Pharmacies will not be able to utilize DUR-PPS codes to bypass therapeutic duplication rejections at point-of-sale. Pharmacies may contact Optum Rx Customer Service (866-434-5520) if the pharmacist determines that an override is needed to allow titration of dose or change in product. A member may receive up to 3 overrides per rolling calendar year.”

This DUR hard edit applies across both GLP-1 Agonists (T2D) and GLP-1 Weight Management Agents classes. A TennCare member cannot concurrently fill Ozempic and Wegovy, or Wegovy and Zepbound, even if they hold separate approved PAs for each. The 85%-refill-threshold rule applies when switching between products or strengths (e.g., moving from Wegovy to Zepbound, or titrating up within the same product).

The January 1, 2026 PA-duration reversal

The same December 1, 2025 provider notice had also announced that initial PA approvals for GLP-1 Weight Management Therapy agents would change to a 3-month duration effective January 1, 2026. That proposal was reversed before it took effect. Verbatim from the January 1, 2026 provider notice:

“OBESITY MANAGEMENT AGENTS UPDATE: On the Provider Notice Weight Management Updates 12.01.25, it was stated that initial prior authorization (PA) durations for GLP-1 Weight Management Agents would be changing to a 3-month duration. After further review, in effort to reduce PA burden on providers and members, the initial authorization length will remain 1 year.”

Initial PA approval duration is currently 1 year. Any source citing a 3-month initial window for TennCare GLP-1 weight-management PA is citing the superseded December 2025 proposal, not current operating rules.

T2D vs. weight-loss prescriptions: the distinction matters

Wegovy and Zepbound are listed on the TennCare PDL in two separate classes — GLP-1 Agonists (T2D) and GLP-1 Weight Management Agents — with different PA forms, different criteria, and different indication-specific renewal rules. The DUR hard edit applies across both classes and prevents concurrent fills regardless of which PA was approved.

Practically:

• A TennCare member with Type 2 diabetes and obesity can receive Wegovy under either the T2D GLP-1 Agonist PA criteria OR the Obesity Management Therapy PA criteria — but only one at a time, and only under one set of criteria at a time.
• Ozempic is the preferred GLP-1 RA for T2D under its own PA criteria. Verbatim: diagnosis of T2D evidenced by A1C ≥ 6.5%, FPG ≥ 126 mg/dL, 2-hour PG ≥ 200 mg/dL, or random PG ≥ 200 mg/dL with classic hyperglycemia symptoms. No metformin step-therapy required.
• Mounjaro (tirzepatide T2D formulation) is non-preferred for T2D. Verbatim PA criteria: same as Ozempic T2D criteria, PLUS “clinically valid reason why the preferred Ozempic agent cannot be used.” Mounjaro is NOT in the GLP-1 Weight Management Agents class and cannot be prescribed for obesity management under TennCare.

Excluded populations and coverage limitations

• Personal or family history of medullary thyroid carcinoma or MEN2: Categorically ineligible for Wegovy, Zepbound, Saxenda, or liraglutide (weight management) across all indications. This is an FDA-label contraindication reflected in every GLP-1 PA criteria document.
• Children under age 12: Not eligible for any FDA-approved GLP-1 weight-management agent under the August 1, 2025 amendment or the May 1, 2026 PA criteria. Imcivree (setmelanotide) is listed under “Obesity Agents for Rare Disorders” as Non-Preferred with PA for patients with Bardet-Biedl syndrome or POMC/PCSK1/LEPR deficiency.
• Adolescents 12–17: Eligible for Wegovy, Saxenda, and generic liraglutide (weight management) per FDA pediatric labels, using BMI ≥ 95th percentile standardized for age and sex. Zepbound is NOT FDA-labeled for ages under 18 and is NOT covered for this population.
• Members with prior CPAP/BiPAP failure and OSA who cannot document BMI ≥ 30: Zepbound OSA requires documented BMI ≥ 30. Members below that threshold may seek Wegovy under MACE or obesity PA criteria if they otherwise qualify.
• CoverKids (Tennessee CHIP, PCN CKDS): Administered through OptumRx but a separate program for higher-income children with separate eligibility rules. Whether CoverKids covers GLP-1 weight-management agents under the same criteria as TennCare Medicaid was not independently verified in the source research for this article; CoverKids members should verify through their CoverKids-specific member documents.
• CoverRx (state-funded prescription discount program, PCN CVRX):This is NOT a Medicaid program. The 2025–2026 TennCare regulatory amendment does not modify CoverRx benefit rules. CoverRx members are not covered under TennCare’s GLP-1 obesity pathway.
• Members filling more than one GLP-1 concurrently:The December 12, 2025 DUR hard edit categorically prevents concurrent GLP-1 fills at the point of sale. Pharmacies cannot use DUR-PPS bypass codes. Up to three OptumRx-issued overrides per rolling calendar year are available for titration or product changes.

Failed prior legislation and the legislative record

The 2025–2026 TennCare expansion was accomplished administratively through regulatory amendment, not through a standalone obesity-drug statute. Two prior legislative attempts in the 113th General Assembly did not advance:

• HB1315 / SB0674 (113th GA, 2023) — Introduced by Representative Doc Kumar (the same physician who co-chaired the 2022 task force). Would have required TennCare to make anti-obesity medication available to recipients if medically necessary. Disposition: “Taken off notice for calendar in the Finance, Ways, and Means Subcommittee on 04/18/2023.” Did not advance to floor passage. This bill was a legislative precursor to the 2025–2026 administrative amendment but was not enacted.
• HB0372 / SB0334 (114th GA, 2025-2026) — “Tennessee Medicaid Modernization and Access Act of 2025” — Status as of April 20, 2026: deferred in the Senate Finance, Ways & Means Committee. This bill addresses TennCare reimbursement rates for obstetrics/gynecology, primary care, outpatient mental health, and substance use disorder treatment — it does NOT address GLP-1 or obesity coverage. It is procedurally and substantively separate from the GLP-1 coverage framework.

The verified legislative record through May 10, 2026 is that no bill currently before the 114th General Assembly’s 2026 second session would (a) terminate TennCare GLP-1 obesity coverage, (b) expand it further, or (c) constrain the Bureau of TennCare’s regulatory authority to maintain or modify the current rule. Coverage continued into 2026 through the administrative-regulatory pathway, not through standalone legislation. Continued coverage in future fiscal years depends on (a) continued appropriation in the annual budget cycle and (b) the Bureau of TennCare’s continued regulatory choice. Neither is statutorily mandated by a standalone obesity-drug law.

Comparison with the prior 12 states: where Tennessee sits

vs. North Carolina (NC, Anchor #9)

NC was a double-reversal state — coverage was continuous since August 1, 2024, briefly terminated October 1, 2025 due to a $319M budget stalemate, and reinstated December 12, 2025 by gubernatorial directive. TN was an explicit-exclusion state through July 31, 2025, then expanded coverage effective August 1, 2025 by emergency rule with permanent rule effective January 26, 2026. TN’s coverage was created; NC’s coverage was reinstated. Both are now positive-coverage states. NC has Wegovy Preferred and Zepbound Non-Preferred; TN has both Wegovy and Zepbound Preferred. NC’s MASH criteria cover F1/F2/F3 (broader); TN covers F2/F3 only. TN’s 10-AOM no-PA panel is more extensive than NC’s.

vs. Michigan (MI, Anchor #10)

MI retained chronic-weight-management coverage but raised the BMI floor to ≥ 40 (morbid obesity) and imposed a uniquely Michigan bariatric-surgery-avoidance prescriber attestation. TN’s BMI thresholds are FDA-label-aligned (> 30 or > 27 with comorbidity) with no state-level floor above the FDA label. TN is substantively broader than MI for chronic weight management.

vs. Pennsylvania (PA, Anchor #7)

PA terminated 34 months of obesity coverage effective January 1, 2026 (fiscal trigger: $836M total-funds savings per year). TN expanded coverage effective August 1, 2025. Both decisions occurred in the same 2025–2026 fiscal-policy window but in opposite directions. TN’s published fiscal projection ($2.7M annual increase) is orders of magnitude smaller than PA’s termination-savings estimate.

vs. California (CA, Anchor #2)

CA reinstated Wegovy ONLY for the FDA MASH indication in March/April 2026 — a narrow, single-indication carve-back-in. TN’s coverage includes chronic weight management (Wegovy + Zepbound + Saxenda + liraglutide) PLUS Wegovy MACE PLUS Wegovy MASH PLUS Zepbound OSA. TN’s breadth is approximately four times CA’s January/March 2026 coverage scope.

vs. Arizona (AZ, Anchor #12)

AZ’s AHCCCS FFS Provider Billing Manual explicitly lists “Medications used for weight loss treatment” as item #13 of the FFS Pharmacy Exclusions — the most operationally direct non-coverage primary source in the series. TN’s Sequence 10-34-25 is the most operationally direct positive-coverage primary source in the series. The two states are mirror-image anchors at opposite ends of the policy spectrum.

vs. New York (NY, Anchor #3)

NY does NOT cover GLP-1s for chronic weight management (anchored in 18 NYCRR § 505.3(g)(3)) but covers Wegovy for MACE via DUR pathway at BMI ≥ 40 with a lifetime two-attempt cap. TN covers GLP-1s for chronic weight management at FDA-label-aligned BMI thresholds, covers Wegovy MACE at BMI ≥ 27 (no attempt cap), covers Wegovy MASH at F2/F3, and covers Zepbound OSA at BMI ≥ 30. TN’s coverage scope is broader than NY’s on every dimension, including the MACE BMI floor (TN: ≥ 27 vs. NY: ≥ 40).

Patient action steps: how to access TennCare GLP-1 coverage

1. Verify TennCare enrollment status. You must be an active TennCare Medicaid member (PCN TNM) or TennCare Standard member. CoverKids and CoverRx members are not covered under this pathway.
2. Identify your TennCare MCO. Your MCO (Wellpoint, BlueCare, UHC, or TennCare Select) determines your medical, behavioral, and dental benefits but does NOT determine your pharmacy coverage. Pharmacy is administered statewide by OptumRx regardless of MCO.
3. Confirm your prescriber is TennCare-enrolled. The PDL header requires all agents to be prescribed by a provider with a Tennessee Medicaid Provider ID. An out-of-state or non-Medicaid-enrolled prescriber cannot prescribe under TennCare pharmacy benefits.
4. Document your obesity diagnosis. BMI > 30 OR BMI > 27 with weight-related comorbidity (hypertension, dyslipidemia, diabetes, CHD, MASH/NASH, or OSA) from medical records (chart notes). For adolescents 12–17: BMI ≥ 95th percentile standardized for age and sex.
5. Your prescriber completes the Weight Management Agents PA Form (for obesity management) or the GLP-1 Agonist PA Form (for T2D, MACE, MASH, or OSA). The prescriber attests to lifestyle modification participation and contraindication absence. Fax to OptumRx Pharmacy Support Center: 866-434-5523.
6. OptumRx reviews the PA request. Initial approval duration is 1 year. There is no published target turnaround time in the verified sources for this article; contact OptumRx member services at 888-816-1680 for status.
7. Fill at any TennCare-network pharmacy. Claims route to BIN 001553 / PCN TNM. The pharmacy will process the claim through OptumRx. If you are switching products or titrating, the 85%-refill-threshold rule applies; the pharmacy may need to contact OptumRx for an override (866-434-5520; up to 3 overrides per rolling calendar year).
8. At renewal (1-year mark): Your prescriber must submit documentation of ≥ 5% weight loss of baseline body weight. If you have not met that threshold but are still on the medication, up to one additional month is available to allow for titration off medication.
9. If Wegovy and Zepbound both fail or are contraindicated:Your prescriber can request Saxenda or generic liraglutide (weight management) as Non-Preferred agents after documenting trial-and-failure of two preferred agents.
10. TennCare also covers traditional AOMs without PA.Phentermine, phentermine/topiramate, benzphetamine, diethylpropion (IR and ER), Lomaira, orlistat (Rx), phendimetrazine (IR and ER), and Xenical are Preferred with quantity limit only and no PA requirement. These may be appropriate options for patients who do not meet GLP-1 PA criteria or who are awaiting PA decisions.

Appeal pathway: TennCare adverse benefit determinations

If OptumRx denies your GLP-1 PA request, you have the right to appeal. The appeal pathway is anchored in Tenn. Comp. R. & Regs. 1200-13-13-.11 (TennCare Medicaid) and 1200-13-14-.11 (TennCare Standard). Verbatim from 1200-13-14-.11:

“Enrollees have the following rights: (a) To appeal adverse actions benefit determinations. Individuals must file within sixty (60) days from the date on the written notice or, if no notice is provided, from the time the enrollee becomes aware of an adverse benefit determination. Enrollees may appeal in person, by telephone, or in writing. For ongoing care, enrollees have the right to continuation or reinstatement of services pending resolution of the appeal when the enrollee submits a timely appeal. Enrollees are entitled to a hearing before a hearing officer with rights including representation, witness examination, and independent medical opinions at no expense to the enrollee. Appeal decisions must be based on an evaluation of pertinent medical evidence.”

Key appeal logistics:

• Filing window: 60 days from the date of the written denial notice.
• How to file: Phone: 1-800-878-3192 (Monday–Friday, 8 a.m.–4:30 p.m. Central Time). Also by mail or online at tn.gov/tenncare/members-applicants/how-to-file-a-medical-appeal.html.
• Standard appeal decision timeline: 90 days.
• Expedited appeal (when OptumRx agrees): approximately one week.
• Required information: Social Security number OR TennCare card number OR date of birth (month, day, year); name of dispensing pharmacy; pharmacy address (if available).
• Independent medical opinion: You are entitled to an independent medical opinion at no expense to you as part of the hearing process.
• If you are currently on the medication and the PA is up for renewal: Submitting a timely appeal may give you the right to continuation of services pending resolution — consult the denial notice for the specific continuation-of-services language.

PA approval is not guaranteed regardless of BMI or diagnosis. This article documents the published criteria; individual PA decisions depend on case-specific medical documentation and OptumRx clinical review. This article does not constitute medical or legal advice.

Related research

• North Carolina Medicaid GLP-1 coverage (2026): the double-reversal state — NC (Anchor #9) and TN (Anchor #13) are the two positive-coverage states in the 13-state cluster. NC’s coverage history is a double-reversal within an ongoing framework (terminated October 2025, reinstated December 2025); TN’s is an expansion from a prior categorical-exclusion baseline (first coverage August 1, 2025). Both list Wegovy as Preferred; TN additionally lists Zepbound as Preferred.
• Wegovy alternatives for weight management — Tennessee is the second state Medicaid program (after NC) where Wegovy is listed as Preferred for the chronic-weight-management indication, and the only state in the series where Zepbound is also Preferred alongside Wegovy in a dedicated GLP-1 Weight Management Agents class.
• Foundayo vs Wegovy vs Zepbound comparison — TennCare is among the most favorable state Medicaid programs for accessing Wegovy and Zepbound with verifiable preferred-PDL status, FDA-label-aligned BMI criteria, and a 1-year initial PA window. Foundayo (orforglipron) is a cash-pay oral option; it does not bill insurance and is not a TennCare pathway.
• GLP-1 medication list: full reference (every FDA-approved drug) — the full formulary context for every GLP-1 listed on the TennCare PDL (Ozempic, Victoza, Wegovy, Zepbound, Saxenda, liraglutide, Mounjaro, Rybelsus, Trulicity, Soliqua, Xultophy) and traditional AOMs in the Appetite and Absorption Agents class.
• GLP-1 insurance-dropped coverage appeal playbook — four-phase appeal logic including TennCare Bureau of Hearings guidance for denials; Tenn. Comp. R. & Regs. 1200-13-13-.11 / 1200-13-14-.11 is the operative appeal anchor.
• Pennsylvania Medicaid GLP-1 coverage (2026): the policy reversal — TN and PA are mirror-image case studies. Both states faced the same 2025–2026 fiscal-policy window; PA terminated 34 months of coverage January 1, 2026 ($836M savings projection), while TN expanded from zero coverage August 1, 2025 ($2.7M expenditure projection).
• New Jersey Medicaid GLP-1 coverage (2026): dual-authority explicit exclusion — NJ FamilyCare excludes GLP-1s for weight management (Anchor #11) while NJ’s state-employee SHBP covers them — the same cross-jurisdictional asymmetry seen in Tennessee (TennCare covers Zepbound; state employee plan does not).
• Michigan Medicaid GLP-1 coverage (2026): partial retainment with morbid-obesity gate — the most instructive comparison for TennCare’s FDA-label-aligned BMI criteria. MI retained coverage but raised the floor to BMI ≥ 40 and added a bariatric-surgery-avoidance attestation found in no other state. TN imposes no state-level BMI floor above the FDA label.
• Massachusetts Medicaid (MassHealth) GLP-1 coverage (2026): two-phase termination policy-reversal — the 12-month inversion mirror. TennCare added obesity coverage August 1, 2025 via Sequence 10-34-25 ($2.7M annual expenditure). MassHealth terminates obesity coverage July 1, 2026 per Pharmacy Facts #271 (~$15M annual savings). Opposite fiscal directions, same calendar window. MA's Phase 2 architecture (MACE + MASH + OSA) is broader than TN’s Wegovy MACE pathway on the OSA dimension (TN covers Zepbound OSA; MA adds Wegovy MACE at the same BMI ≥ 27 threshold as TN).

Last verified: May 10, 2026. Primary sources: Sequence 10-34-25 (effective 1/26/2026; TN Dept. of State); TennCare PDL effective May 1, 2026 (OptumRx); Clinical Criteria document effective May 1, 2026 (OptumRx); August 1, 2025 OptumRx Provider Notice; January 1, 2026 OptumRx Provider Notice; December 1, 2025 OptumRx Provider Notice; 2025 Public Chapter No. 530 (HB1409); 2022 Chronic Weight Management Task Force Final Report; KFF January 2026 Medicaid GLP-1 tracker; State of Tennessee Group Insurance Program formulary effective 10/01/2025. TennCare PDL and PA criteria are subject to Pharmacy Advisory Committee (PAC) quarterly review and may change. Confirm with OptumRx (888-816-1680) or tn.gov/tenncare before making clinical or financial decisions.