# Does Michigan Medicaid Cover Wegovy or Zepbound? BMI 40 and the Five-Drug Rule By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-06 Canonical page: https://glpwatchdog.org/research/michigan-medicaid-glp1-coverage > A 2025 Michigan budget law limited anti-obesity GLP-1s to morbid obesity and to averting bariatric surgery. The state's criteria turn that into five older drug types, a BMI of 40 and a 5% renewal test, with a far lower bar for heart, liver and sleep apnea uses. ## Key points - A 2025 Michigan budget act limited weight-loss GLP-1s to morbid obesity; the 2026 act keeps the limit unless the state joins a federal drug savings program. - A request must first work through benzphetamine, diethylpropion, orlistat, phendimetrazine and phentermine. - The prescriber must state that the drug is meant only to head off costlier surgery. - Wegovy for heart disease or MASH, plus Zepbound for sleep apnea start at a BMI of 27. - Renewal every six months generally requires keeping off 5% of starting weight. Only for a narrow group. As of November 2026 Michigan Medicaid will approve Wegovy or Zepbound for weight loss only at a BMI of 40 or more, after trial and failure of five types of older drugs, and only as a way to avoid bariatric surgery.[2] Other uses face a far lower bar: Wegovy for heart disease or the liver disease MASH and Zepbound for sleep apnea each start at a BMI of 27.[2] > **About this article.** This page reads Michigan’s budget act and the state’s Medicaid pharmacy criteria revised November 1, 2026. For the federal rule underneath, see [why Medicaid treats Ozempic and Wegovy differently](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy). ## Why did Michigan Medicaid restrict GLP-1s for weight loss? Because the legislature told it to. Section 1880 of the 2025 budget act directed the health department to limit anti-obesity GLP-1s to people classified as morbidly obese, to make coverage depend on documented failure of other suitable interventions, and to treat the drug only as a way around costlier weight-loss surgery.[1] The new criteria applied from January 1, 2026, to every Michigan Medicaid member, whichever plan they use.[5] The budget for the year that began October 1, 2026, repeats the limit, now worded as class III obesity, but only if the department does not take part in a federal pharmaceutical savings program that year. The act does not name a program.[13] The criteria revised November 1, 2026, still apply the limit, so watch for a change if Michigan joins one.[2] States may limit these drugs under federal law, and Michigan chose a middle path: unlike [Illinois](https://glpwatchdog.org/research/illinois-medicaid-glp1-coverage) and [Arkansas](https://glpwatchdog.org/research/arkansas-medicaid-glp1-coverage), which do not cover weight loss alone, it kept a route, but one few people can reach.[8] ## What does it take to get Wegovy or Zepbound approved for weight loss? 1. **Five types of older drugs first.** Allergy, contraindication, side effects, or trial and failure must cover benzphetamine, diethylpropion, an orlistat product, phendimetrazine and a phentermine product.[2] 2. **A BMI that counts as morbid obesity.** The criteria give a baseline BMI of 40 or more as the example for adults. For ages 12 to 17, the prescriber attests the child is classified that way on CDC growth charts.[2] 3. **Two attestations from the law.** The prescriber confirms that other suitable interventions failed and that the drug is a last step before an operation the state wants to avoid paying for.[1][2] 4. **The right age for the product.** Age 18 for Zepbound, Wegovy tablets and Wegovy HD; age 12 for the Wegovy injection, Saxenda, liraglutide and Foundayo.[2] 5. **Clinical screens.** No second weight-loss drug, no DPP-4 inhibitor, other causes of obesity ruled out or treated, no pregnancy, lactation, medullary thyroid cancer or MEN 2, and a diet and activity plan suited to the person’s ability.[2] The first step is the part a BMI headline hides. Approval runs six months, and renewal requires keeping off at least 5% of starting weight, or for children, holding or improving BMI percentile.[2] So getting through can take many months of other medication before a GLP-1 request is even complete. Each older drug carries its own prior authorization, starting at a BMI of 30, or 27 with a risk factor such as hypertension.[4] Our comparison of [phentermine and a GLP-1](https://glpwatchdog.org/research/phentermine-vs-a-glp1) sets out how much less those drugs tend to do. The surgery language is also unusual, because the criteria ask for an attestation, not a surgical referral or evaluation. The state does not spell out what would satisfy it. Our page on [surgery versus GLP-1 drugs](https://glpwatchdog.org/research/surgery-versus-glp1-drugs) explains how far apart the two are on weight, which is useful context when a request has to weigh one against the other. ## Does Michigan Medicaid cover Wegovy for heart disease? Yes, with prior authorization, and without the five-drug step. Michigan has separate classes for each non-weight use, with their own forms and tests.[3] The table shows how different they are from the weight-loss route. *Michigan Medicaid GLP-1 routes from the criteria revised November 1, 2026. Each first approval and renewal runs six months.* | Route | Age | BMI | Main test | Renewal | | --- | --- | --- | --- | --- | | Wegovy or Zepbound, weight loss | 12 or 18, by product | Morbid obesity (40 or more in adults) | Five older drug types; surgery attestation | 5% of starting weight kept off | | Wegovy, heart risk | 18+ | 27+ | Established heart disease, for example a past heart attack or stroke, or disease of the leg arteries | Still has the disease; no weight line printed | | Wegovy, MASH | 18+ | 27+ | Noncirrhotic MASH with F2 to F3 fibrosis | 5% of starting weight kept off | | Zepbound, sleep apnea | 18+ | 27+ | Documented moderate to severe sleep apnea | 5% of starting weight kept off | Michigan’s heart route is more open than some others: it has no age-45 line, matching a label written for adults.[2][9] Compare [Texas, which starts at 45](https://glpwatchdog.org/research/texas-medicaid-glp1-coverage). The criteria file we read prints the heart renewal’s first line, ending in “AND,” and then no second condition, so ask whether a weight test applies.[2] ## Does Michigan Medicaid cover Zepbound for sleep apnea? Yes. Zepbound is the preferred drug in its own sleep apnea class.[3] The request needs a documented moderate to severe diagnosis and a BMI of 27 or more, and the criteria we read list no specific apnea-hypopnea number or trial of CPAP.[2] That BMI floor is below the label’s use, which is for adults with obesity, so a prescriber should be ready to explain a lower-BMI request.[10] Vials are not covered by Medicaid, according to the state’s change log, while the KwikPen is on the list.[2] See [Zepbound for sleep apnea](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) for the evidence behind the use. ## Does Michigan Medicaid cover Wegovy for MASH? Yes, for adults with noncirrhotic MASH and moderate to advanced fibrosis, consistent with stages F2 to F3, and a BMI of 27 or more.[2] Michigan’s criteria rely on the prescriber’s attestation and do not name a required test or time window, though renewal asks for 5% of starting weight kept off.[2] Someone who loses less than that should raise it with the prescriber before renewal. Our guide to [GLP-1s and fatty liver](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) covers the trial. ## What happens to people who were already taking Wegovy or Zepbound? Existing approvals ran to the end of the current authorization, and renewals then met the new rules.[5] The criteria include a transition step for the first renewal: the prescriber confirms the person met the morbid obesity label at the start, that other interventions had failed, and that surgery avoidance was the purpose, and adds the 5% weight record.[2] A patient whose starting BMI fell short has no route for weight loss, and should check whether a heart, liver or sleep use applies. ## Does Michigan Medicaid cover Ozempic for diabetes? Yes. The budget change did not touch diabetes coverage.[5] The criteria ask for a type 2 diabetes diagnosis and that other GLP-1s and DPP-4 inhibitors are stopped, with approval lasting a year.[2] The state’s change log shows Ozempic and Mounjaro moved to preferred status and Ozempic tablets added as non-preferred, so check the current list.[2] A non-preferred product generally needs a trial of a preferred one in the same group first.[2] ## How do you appeal a denial in Michigan? - **Plan appeal.** Federal rules give you 60 calendar days from the notice.[7] - **State fair hearing.** One Michigan plan tells members they have 120 calendar days from the mailed appeal denial.[6] - **External review.** The same plan describes a request to the state insurance regulator within 127 calendar days.[6] Appeals work best on the record: a missed trial that was in fact tried, or a BMI that was measured at baseline. Our guide to [prior authorization and appeals](https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals) shows what to include. A prescriber should not record a diagnosis you do not have. ## What are the options if you don't qualify? The older drugs are the covered path, and the department also suggests diabetes prevention programs.[2][3] Cash is the other route, and Lilly’s savings card excludes government programs.[11] Prices in the figures we track are $349 a month for most Wegovy pen doses from Novo Nordisk, and from $299 at the starting dose up to $449 at higher doses for Lilly’s Zepbound KwikPen or vial.[11][12] Check each offer’s terms for Medicaid members. The guide to the [lowest GLP-1 prices without insurance](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them. ## Frequently asked questions ### Does Michigan Medicaid cover Wegovy for weight loss? Only in narrow cases. As of November 2026, an adult generally needs a baseline BMI of 40 or more, trial and failure of five types of older weight-loss drugs, and a prescriber's statement that the drug is meant to avoid surgery. Approval lasts six months. ### Does Michigan Medicaid cover Zepbound? Yes for moderate to severe sleep apnea with a BMI of 27 or more, with prior authorization. For weight loss, it faces the same BMI 40 and five-drug requirements as Wegovy. Renewal on both routes requires keeping off at least 5% of starting weight. ### Does Michigan Medicaid cover Ozempic? Yes, for type 2 diabetes with prior authorization. The 2026 weight-loss limits did not change diabetes coverage. Ozempic is not a covered route for weight loss. ### What weight-loss drugs does Michigan Medicaid prefer? Benzphetamine, diethylpropion, orlistat products, phendimetrazine and phentermine products, including phentermine with topiramate. They still require prior authorization, starting at a BMI of 30, or 27 with a listed risk factor. ### Do I need to have bariatric surgery planned to get a GLP-1 on Michigan Medicaid? The criteria we read do not require a surgical referral. The prescriber must confirm that the GLP-1 is meant only as a way to avoid costlier surgery. Ask your prescriber or plan how they document that. ## References 1. State of Michigan, 103rd Legislature Public Act 22 of 2025, section 1880. legislature.mi.gov. 2025. https://www.legislature.mi.gov/documents/2025-2026/publicact/pdf/2025-PA-0022.pdf 2. Prime Therapeutics for Michigan Department of Health and Human Services Michigan Medicaid Clinical and PDL Criteria, revised November 1, 2026. mi.primetherapeutics.com. 2026. https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_clinical_criteria.pdf 3. Prime Therapeutics for Michigan Department of Health and Human Services Single PDL Classes containing GLP-1 Anti-Obesity Agents starting January 1, 2026. mi.primetherapeutics.com. 2026. https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_Single_PDL_classifications.pdf 4. Michigan Department of Health and Human Services Prescription Drug Prior Authorization Form: Anti-Obesity/Non-GLP1 Medications, revised January 1, 2026. mi.primetherapeutics.com. 2026. https://mi.primetherapeutics.com/provider/external/medicaid/mi/doc/en-us/MIRx_PAfaxform_anti-obesity_medications.pdf 5. Priority Health GLP-1 weight-loss drug coverage changes coming for Medicaid members, December 15, 2025. priorityhealth.com. 2025. https://www.priorityhealth.com/provider/manual/news/pharmacy/12-15-2025-medicaid-glp1-coverage-changes-effective-jan-1-2026 6. CareSource Michigan State Hearing and External Review, Medicaid. caresource.com. 2026. https://www.caresource.com/mi/members/tools-resources/grievance-appeal/state-hearing-external-review/medicaid/ 7. Code of Federal Regulations 42 CFR §438.402: Statutory basis and general requirements (managed care appeals). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/cfr/text/42/438.402 8. United States Code 42 U.S.C. §1396r-8: Payment for covered outpatient drugs. Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396r-8 9. Novo Nordisk WEGOVY (semaglutide): prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b 10. Eli Lilly and Company ZEPBOUND (tirzepatide) injection: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b 11. Eli Lilly and Company Zepbound savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings 12. Novo Nordisk Wegovy savings offer. novocare.com. 2026. https://www.novocare.com/obesity/products/wegovy/savings-offer.html 13. State of Michigan, 103rd Legislature Public Act 21 of 2026 (Enrolled Senate Bill 878), section 1880. legislature.mi.gov. 2026. https://www.legislature.mi.gov/documents/2025-2026/publicact/pdf/2026-PA-0021.pdf --- Cite as: GLP Watchdog, Nora Bissett, "Does Michigan Medicaid Cover Wegovy or Zepbound? BMI 40 and the Five-Drug Rule", published 2026-11-06. https://glpwatchdog.org/research/michigan-medicaid-glp1-coverage Canonical HTML page: https://glpwatchdog.org/research/michigan-medicaid-glp1-coverage Medical disclaimer: Nothing here is medical advice. We report on this subject; we do not treat anyone. Whether to begin a medication, supplement, or treatment, whether to adjust it, and whether to stop are questions for a clinician licensed to answer them, who knows your history.