CurrentNorth Carolina MedicaidPolicy N/A

GLP-1 Medications for Weight Management

Customize your policy alerts

Sign up for all North Carolina Medicaid policy alerts

Know when North Carolina Medicaid releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs NC Medicaid outpatient pharmacy prior approval for Saxenda, Wegovy, and Zepbound when used for weight management, with separate initial and renewal criteria for adults and adolescents.

Policy Summary

PayerNorth Carolina Medicaid

PolicyGLP-1 Medications for Weight Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior approval for beneficiaries under 21 years of age; EPSDT does not eliminate the prior approval requirement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3GLP-1 weight-management products

6 monthsInitial approval

12 monthsRenewal approval

5%Adult renewal threshold

>4%

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentNorth Carolina MedicaidPolicy N/A

GLP-1 Medications for Weight Management

Customize your policy alerts

Sign up for all North Carolina Medicaid policy alerts

Know when North Carolina Medicaid releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNorth Carolina Medicaid

PolicyGLP-1 Medications for Weight Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior approval for beneficiaries under 21 years of age; EPSDT does not eliminate the prior approval requirement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3GLP-1 weight-management products

6 monthsInitial approval

12 monthsRenewal approval

5%Adult renewal threshold

>4%

Adolescent renewal threshold

3–6 monthsPreferred-drug trial

Coverage Criteria

Renewal Therapy

Renewal requires prior Medicaid approval and all continuing-treatment requirements.

Renewal requirements

Maintained clinical response: Adults have lost a total of 5% of pretreatment weight and maintain the 5% weight loss; adolescents aged greater than 12 and less than 18 years have achieved more than 4% reduction in baseline BMI and maintain the weight loss; or an adult or adolescent has a prescriber-documented significant reduction from BMI that is maintained even though the standard threshold is not met, with rationale provided.Adults: 5% weight loss; adolescents: >4% baseline BMI reduction
Baseline and current weight must be provided on the PA form. For the alternative significant-reduction pathway, provide the prescriber's rationale, baseline weight, and current weight.
Continuing lifestyle and safety requirements: The beneficiary is currently following and will continue lifestyle modification, including structured nutrition and physical activity; will not use the requested agent with another GLP-1 receptor agonist; and does not have an FDA-labeled contraindication to the requested agent.

Combination therapy is excluded. The requested agent must not be used with another GLP-1 receptor agonist during treatment, including renewal therapy.

Coverage is excluded when the beneficiary has an FDA-labeled contraindication to the requested agent. Examples include pregnancy, lactation, a history of medullary thyroid cancer, or multiple endocrine neoplasia type II.

Clinical Thresholds and Coding Reference

Therapeutic Class Codesmixed

J8E	ANTI-OBESITY GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST
J8G	ANTI-OBESITY - INCRETIN MIMETICS COMBINATION

Adult obesity threshold

PopulationAdults 18 years or older

ThresholdBMI >= 30 kg/m2

Coverage pathwayAdult obesity

Adult overweight threshold with comorbidity

PopulationAdults 18 years or older

ThresholdBMI >= 27 kg/m2

Additional requirementAt least one weight-related comorbidity, risk factor, or complication

Prior Approval and Documentation Actions

Prior Authorization

Prior Approval Still Required Under EPSDT

Beneficiaries under age 21 are not exempt from prior approval when the requested service, product, or procedure requires it. EPSDT does not waive the PA requirement.

See the NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional EPSDT and prior approval information.

Step Therapy

Complete the Preferred-Drug Trial and Titration

When applicable, the preferred drug for the PA indication must be used before requesting a non-preferred agent. The preferred-drug trial must include adequate titration and sufficient time to determine the member’s side-effect profile.

Document a 3–6 month preferred-drug trial, as applicable.
GLP-1 titration may take up to 6 months.
Failure of the preferred drug is considered a qualifying drug trial and failure of the 3–6 month period unless a documented contraindication exists.

Policy Background

This policy addresses NC Medicaid outpatient pharmacy coverage for anti-obesity GLP-1 receptor agonists and related incretin-mimetic therapy used for weight management in beneficiaries who are overweight or obese. Coverage decisions consider age-specific weight or BMI criteria, qualifying comorbidities or cardiovascular disease when applicable, lifestyle modification, and continued treatment response.

Key Definitions

EPSDT

MeaningEarly and Periodic Screening, Diagnostic, and Treatment

Legal basis42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]

RequirementThe state Medicaid agency must cover medically necessary services, products, or procedures for beneficiaries under 21 years of age to correct or ameliorate an identified defect, illness, or condition

Weight-related comorbidity, risk factor, or complication

HypertensionQualifying weight-related comorbidity, risk factor, or complication

Type 2 diabetesQualifying weight-related comorbidity, risk factor, or complication

Policy Summary

PayerNorth Carolina Medicaid

PolicyGLP-1 Medications for Weight Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2024

Next Review DateN/A

Key ActionSubmit prior approval for beneficiaries under 21 years of age; EPSDT does not eliminate the prior approval requirement.

SourceLink

On This Page

Adolescent BMI percentile threshold

PopulationBeneficiaries 12 through 17 years

ThresholdBMI >= 95th percentile for age and sex

Coverage pathwayAdolescent obesity based on BMI percentile

Adolescent absolute BMI threshold

PopulationBeneficiaries 12 through 17 years

ThresholdBMI >= 30 kg/m2

Coverage pathwayAdolescent obesity based on absolute BMI

Adolescent overweight threshold with severe comorbidity

PopulationBeneficiaries 12 through 17 years

ThresholdBMI >= 85th percentile for age and sex

Additional requirementAt least one severe weight-related comorbidity, risk factor, or complication

Adult cardiovascular disease criterion

Age requirementAge >= 45 years

BMI requirementBMI >= 27 kg/m2

Clinical requirementEstablished cardiovascular disease

Adult renewal response

PopulationAdults renewing therapy

Response threshold5% reduction from pretreatment weight

Continuation requirementMaintenance of the 5% weight loss

Adolescent renewal response

PopulationAdolescents greater than 12 and less than 18 years

Response threshold>4% reduction in baseline BMI

Continuation requirementMaintenance of the weight loss

Baseline measurement recency

Required measurementsBaseline weight and BMI

TimingMeasured within the past 45 days of the submitted PA

Documentation locationPA form

Prior Authorization

Approval Duration and Renewals

Initial approval is limited to 6 months. Renewal approvals are issued for 12 months, with no limit on the number of renewals that may be provided when renewal criteria continue to be met.

Initial approval: 6 months.
Renewal approval: 12 months.
Renewals are not limited in number.

Step Therapy

Preferred Drug Required Before Non-Preferred Therapy

The preferred drug, if applicable, is required for the PA indication unless the beneficiary meets the non-preferred PDL PA criteria. Requests for a non-preferred agent must address the applicable preferred-drug requirement and document the qualifying exception or failure.

Use the preferred drug before non-preferred therapy when applicable.
For a non-preferred drug, document satisfaction of the non-preferred PDL PA criteria.
A documented contraindication to the preferred drug may support an exception to the trial requirement.

Documentation Required

Document Baseline Weight, BMI, and Clinical Information

Provide baseline clinical measurements and supporting information on the PA form. Baseline weight and BMI must be measured within 45 days before the PA is submitted.

Document baseline weight.
Document baseline BMI.
For beneficiaries age 45 or older with BMI ≥27 kg/m² and established CVD, document the qualifying history of myocardial infarction, stroke, or symptomatic peripheral disease on the PA form.

Documentation Required

Document Response for Renewal

For renewal, provide baseline and current weight information on the PA form to demonstrate the required response and maintenance of weight loss.

Adults: document at least 5% reduction from pretreatment weight and maintenance of that loss.
Adolescents older than 12 and younger than 18: document more than 4% reduction in baseline BMI and maintenance of the loss.
If the standard threshold is not met, document a prescriber-determined significant BMI reduction, explain the rationale, and provide baseline and current weight.

Documentation Required

Document Lifestyle and Safety Monitoring

Document that the beneficiary is currently following and will continue lifestyle modification with structured nutrition and physical activity. Physical activity may be omitted only when it is not clinically appropriate when GLP-1 therapy begins.

Record structured nutrition intervention.
Record ongoing physical activity or the clinical reason activity is not appropriate at therapy initiation.
For renewals, confirm continued structured nutrition and physical activity.
Document safety monitoring and assess for FDA-labeled contraindications before and during therapy.

Denial Risk

Product, Dosing, or Preferred-Drug Criteria Not Met

The request may be denied when the product, indication, age, weight, dosing, or preferred-drug requirements are not satisfied.

The product must be FDA approved for the requested indication and the beneficiary’s age and weight, when applicable.
The prescribed dose must not exceed the limits in the Prescribing Information.
The applicable preferred-drug or non-preferred PDL criteria must be met.
Requests that do not meet the product, dosing, or PDL requirements are not approvable.

Denial Risk

Initial Clinical Criteria Not Met

Initial therapy requires a qualifying weight-management indication and the beneficiary must be new to therapy or attempting a repeat weight-loss course. Requests may be denied when the applicable obesity, overweight, comorbidity, or cardiovascular criteria are not met.

Adults age 18 or older: BMI ≥30 kg/m², or BMI ≥27 kg/m² with at least one weight-related comorbidity, risk factor, or complication such as hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, or dyslipidemia.
Beneficiaries ages 12–17: BMI ≥95th percentile for age and sex, BMI ≥30 kg/m², or BMI ≥85th percentile with at least one severe weight-related comorbidity, risk factor, or complication.
Beneficiaries age 45 or older: BMI ≥27 kg/m² with established CVD, defined as a history of myocardial infarction, stroke, or symptomatic peripheral disease.

Denial Risk

Renewal Response Criteria Not Met

Renewal may be denied if the beneficiary was not previously approved for the requested agent through Medicaid PA, is not continuing the current weight-loss course, or has not demonstrated and maintained the required response.

A beneficiary without prior Medicaid approval requires initial evaluation review.
Adults must lose and maintain 5% of pretreatment weight, unless the prescriber documents a significant alternative BMI reduction and rationale.
Adolescents older than 12 and younger than 18 must achieve and maintain more than 4% reduction in baseline BMI.
Baseline and current weight or BMI-response information must be provided on the PA form.

Denial Risk

Combination Therapy or Contraindication

The requested agent must not be used with another GLP-1 receptor agonist and must not be prescribed when an FDA-labeled contraindication applies.

Deny or do not approve concurrent use with another GLP-1 receptor agonist.
Screen for FDA-labeled contraindications, including pregnancy, lactation, a history of medullary thyroid cancer, or multiple endocrine neoplasia type II.
Document that neither combination therapy nor a contraindication is present.

Obstructive sleep apnea, cardiovascular disease, or dyslipidemia

Additional listed qualifying examples

Established cardiovascular disease

Myocardial infarctionHistory of myocardial infarction qualifies as established cardiovascular disease

StrokeHistory of stroke qualifies as established cardiovascular disease

Symptomatic peripheral diseaseHistory of symptomatic peripheral disease qualifies as established cardiovascular disease