BALANCE Model and Medicaid GLP-1 Coverage: How to Check Your State

If you are on Medicaid and hoping a GLP-1 medication will be covered for weight loss, the answer starts with where you live. There is no single national Medicaid rule for this. Each state decides whether to cover GLP-1s for weight management, and the answers have changed often over the past year.

A federal program called the BALANCE Model gives states a new way to cover these drugs. Here is what CMS and several states’ own Medicaid documents say as of 2026-10-16, and how to get a real answer for your state and plan.

Transformation Health is an independent guide, not a provider, and is not affiliated with CMS or any state Medicaid program: we do not prescribe, sell medication, or work with insurance. This content is for general education and is not medical advice. Talk with a licensed provider about your situation.

The short answer

Covering GLP-1s for weight loss is optional for state Medicaid programs. The federal Medicaid drug rebate law lists “agents when used for anorexia, weight loss, or weight gain” among the drugs a state may exclude from coverage or otherwise restrict.^[1] CMS says that currently, Medicare and Medicaid generally do not cover these drugs for the weight loss indication.^[2]

That is why the answer differs by state. Some states cover GLP-1s for weight loss with prior authorization, some have narrowed or ended that coverage, and some never covered it. GLP-1s prescribed for type 2 diabetes or another FDA-approved use outside weight loss are a separate coverage question. This page is about coverage for weight management.

The only reliable answer for you comes from your own state. Call your state Medicaid agency or your Medicaid managed care plan’s member services, and ask for your state’s preferred drug list and prior authorization criteria for GLP-1 weight management drugs.

What is the BALANCE Model?

BALANCE stands for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth. It is a voluntary model run by the CMS Innovation Center under section 1115A of the Social Security Act.^[2] As of 2026-10-16, here is what CMS’s own documents say.

CMS negotiates; states choose whether to join. CMS negotiates drug pricing and coverage terms with GLP-1 manufacturers on behalf of state Medicaid agencies and Medicare Part D plans. Participation is voluntary for manufacturers, states, and Part D plans.^[2] Any state, the District of Columbia, or territory that takes part in the Medicaid Drug Rebate Program can apply.^[3]

Timeline for states. CMS says state Medicaid agencies can join beginning in May 2026 through January 1, 2027.^[2] The State Request for Applications set a July 31, 2026 application deadline and requires a signed State Agreement with CMS by January 1, 2027; states that miss that date may join later only at CMS discretion. A state can start with its fee-for-service population and add managed care later, but all of its Medicaid populations must be in the model by January 1, 2027. The model runs through December 2031.^[3]

Drugs included. The CMS page lists all formulations of Mounjaro, Ozempic, Rybelsus, and Wegovy, the KwikPen formulation of Zepbound, and Foundayo, for both currently covered uses such as type 2 diabetes and weight management.^[2]

Coverage criteria. Participating states adopt coverage criteria negotiated between CMS and the manufacturers, and must apply them the same way in fee-for-service Medicaid and in Medicaid managed care plans. People getting a model drug for weight management must be 18 or older.^[3] The State Request for Applications lists these criteria, which states may make less restrictive but not more:^[3]

Lifestyle support. CMS says everyone getting a GLP-1 for weight management under the model in Medicaid will have access to a lifestyle support program, provided by the manufacturer at no cost.^[2]

No guarantee. CMS says coverage in Medicaid depends on participation by manufacturers and states, that patients are subject to the negotiated qualifications, including prior authorization, and that the model “will not guarantee coverage for any individual."^[2] The negotiated prices are shared with states confidentially.^[3]

No public list of states. As of 2026-10-16, CMS has not published a list of participating states; its BALANCE page shows the number of participants as “N/A."^[2] Some states have made their own announcements. Until your state Medicaid agency publishes a provider bulletin, preferred drug list change, or member notice with a start date and criteria, treat any report about your state as unconfirmed and ask the agency directly.

Medicare is separate. As of 2026-10-16, CMS says the BALANCE Model is not expected to launch in Medicare in 2027. CMS is instead running the Medicare GLP-1 Bridge, a short-term demonstration for eligible Medicare Part D enrollees from July 1, 2026 through December 31, 2027.^[2][4] If you are on Medicare, see our guides to the Medicare GLP-1 Bridge and Medicare Part D and GLP-1 coverage.

What some states’ own Medicaid documents say

Each row comes from that state’s Medicaid agency document, read on 2026-10-16. This is not a complete list of states, and it does not say whether any state has joined BALANCE. If your state is not here, that tells you nothing about its coverage; check its preferred drug list and prior authorization criteria.

A few cautions. State Medicaid coverage has moved in both directions recently, and a state that joins BALANCE may change its criteria to match the model. Your plan’s member services can tell you exactly which criteria apply to you today. Date-check any coverage claim you read, including this page.

How to check your own state

Call your Medicaid managed care plan or your state Medicaid agency. If you are in a managed care plan, the member services number on your card is usually the fastest route. If you are in fee-for-service Medicaid, call your state Medicaid agency. Ask four questions:

1. Does my plan cover GLP-1 medications for weight management, not only for diabetes?
2. If yes, which drugs are preferred, and what do the prior authorization criteria require?
3. Has the state joined the CMS BALANCE Model, and if so, when does coverage start for my plan?
4. Where can I read the current preferred drug list and prior authorization criteria?

Write down the date and the name of the person you spoke with, because these rules change.

Read your state’s preferred drug list and criteria. Most state Medicaid programs post a preferred drug list (PDL) and prior authorization criteria for each drug class. Look for a weight management or anti-obesity class. Provider bulletins on the state Medicaid website announce changes and effective dates.

Expect prior authorization where coverage exists. States that cover these drugs for weight loss attach criteria, typically a BMI threshold, documented weight-related conditions, and evidence of a diet and activity program. Your prescriber submits the request. Our guide to GLP-1 prior authorization explains the documentation these requests usually need.

What you pay if it is covered. Federal rules set the maximum cost sharing a state can charge for prescription drugs, and some enrollees are exempt from cost sharing.^[11] Your state and plan set the exact copay. On Medicaid, the bigger question is usually whether the drug is covered for weight management at all.

If your state does not cover

What you do next depends on why the answer was no.

Your request was denied under criteria your state does use. This is often fixable with better documentation. You also have the right to a state fair hearing. Federal rules require states to give you a reasonable time to ask for one, not more than 90 days from the date the notice of action is mailed; your notice gives your state’s exact deadline.^[12] Managed care plans also have their own appeal step, which your plan notice explains. Our guide on what to do when coverage says no covers how to read a denial.

Your state excludes weight loss drugs. A fair hearing generally cannot add a benefit your state has not adopted. You can still:

• Ask about a separate covered use. GLP-1s prescribed for other FDA-approved uses, such as type 2 diabetes, are handled differently; several of the state documents above say coverage for those uses continues.^[5][6][7][8] Ask your prescriber whether any covered use applies to you. The criteria are specific, so do not assume.
• Ask whether your state has joined BALANCE. If it has, ask your state Medicaid agency or plan when coverage begins and which criteria apply.
• Look at manufacturer self-pay options. Novo Nordisk and Eli Lilly each publish savings and self-pay terms, and the terms change. Our page on GLP-1 savings programs compares them.
• Look at cash-pay telehealth programs. Some prescribe brand-name medications and some prescribe compounded medications. Compounded medications are not FDA-approved. The FDA does not review them for safety, effectiveness, or quality, and they are not the same as brand-name products.^[13] Our page on compounded GLP-1 without insurance explains how that route works.

Prices vary by program, medication, and dose. Compare the total cost: medication, dose increases, visits, labs, shipping, membership fees, and cancellation terms. At most telehealth programs, a licensed provider reviews your health history and decides whether a prescription is appropriate. Our page on what insurance covers for weight loss and the full insurance coverage overview can help you weigh the options.

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Citations

[1] 42 U.S.C. 1396r-8(d)(2)(A) (drugs that may be excluded or restricted: “agents when used for anorexia, weight loss, or weight gain”). Accessed 2026-10-16. https://www.law.cornell.edu/uscode/text/42/1396r-8

[2] Centers for Medicare and Medicaid Services. “BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model.” Page last modified September 29, 2026. Accessed 2026-10-16. https://www.cms.gov/priorities/innovation/innovation-models/balance

[3] Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. “BALANCE Model Request for Applications: State Medicaid Agency.” Last modified March 2026. Accessed 2026-10-16. https://www.cms.gov/priorities/innovation/files/balance-state-medicaid-rfa.pdf

[4] Centers for Medicare and Medicaid Services. “Medicare GLP-1 Bridge.” Accessed 2026-10-16. https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge

[5] California Department of Health Care Services, Medi-Cal Rx. “GLP-1 Drugs: Medi-Cal Rx Members’ Frequently Asked Questions (FAQs),” Version 5.0, April 6, 2026. Accessed 2026-10-16. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/faq/Members_State_Budget_Policy_Updates_FAQ.pdf

[6] Pennsylvania Department of Human Services. Medical Assistance Bulletin, “Coverage Change and Prior Authorization of GLP-1 Receptor Agonists,” issued November 24, 2025, effective January 1, 2026. Accessed 2026-10-16. https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/docs/publications/documents/forms-and-pubs-omap/mab2025112403.pdf

[7] Michigan Department of Health and Human Services. Numbered Letter L 25-73, “Update of Pharmacy Drug Coverage for Treatment of Obesity,” December 8, 2025. Accessed 2026-10-16. https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Assistance-Programs/Medicaid-BPHASA/2025-L-Letters/Numbered-Letter-L-25-73-Pharmacy-Final.pdf

[8] North Carolina Department of Health and Human Services, NC Medicaid. “NC Medicaid to Reinstitute Coverage of GLP-1s for Weight Management,” December 19, 2025. Accessed 2026-10-16. https://medicaid.ncdhhs.gov/blog/2025/12/19/nc-medicaid-reinstitute-coverage-glp-1s-weight-management

[9] North Carolina Department of Health and Human Services, NC Medicaid. “NC Medicaid Preferred Drug List,” effective October 1, 2026. Accessed 2026-10-16. https://medicaid.ncdhhs.gov/nc-medicaid-preferred-drug-list-pdl-effective-october-2026/download?attachment=

[10] Virginia Department of Medical Assistance Services. “Service Authorization (SA) Form: Weight-Loss Management,” effective July 1, 2026. Accessed 2026-10-16. https://www.virginiamedicaidpharmacyservices.com/provider/external/medicaid/vamps/doc/en-us/VAMPS_SAform_Weight_Loss_Management.pdf

[11] 42 CFR 447.53 (Medicaid cost sharing for drugs). Accessed 2026-10-16. https://www.law.cornell.edu/cfr/text/42/447.53

[12] 42 CFR 431.221(d) (Medicaid fair hearing requests: reasonable time, not to exceed 90 days). Accessed 2026-10-16. https://www.law.cornell.edu/cfr/text/42/431.221

[13] U.S. Food and Drug Administration. “Compounding and the FDA: Questions and Answers.” Accessed 2026-10-16. https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers

Important disclosures

Coverage information on this page is current as of 2026-10-16, is general and educational, and changes frequently. It does not represent the terms of your specific plan and is not legal advice. State Medicaid programs set coverage, and BALANCE participation is decided state by state. Confirm current benefits, preferred drug list status, and prior authorization requirements directly: call your state Medicaid agency or your Medicaid managed care plan’s member services.