Medicaid drug coverage is not one size fits all—and 2025–2026 brings some of the biggest shifts in years. Below, we break down the federal rules now in force, how states are handling GLP-1 weight-loss drugs and sickle cell gene therapies, and where to click to confirm your state’s latest PDL.
What changed federally for 2025–2026?
The MDRP Final Rule (effective late 2024 into 2025/2026)
CMS’s September 26, 2024 Medicaid Drug Rebate Program (MDRP) Final Rule tightened program integrity (drug misclassification corrections), aligned regs with the rebate cap removal (effective 2024), and set additional dates that flow into 2025 and the first Medicaid managed-care rating periods after Nov 19, 2025. For states and MCOs, this means more consistent pricing data, stronger oversight, and contracts that reflect the new federal terms. (Source: Federal Register “CMS-2434-F” & legal summaries; last checked: Oct 8, 2025.) Federal Register+2Arnold & Porter+2
Bottom line: Expect cleaner rebate mechanics and updates to managed-care contracts in 2025–2026 that cascade into formularies and utilization management.
CMS Cell & Gene Therapy (CGT) Access Model (2025–2026)
Starting January 2025 through January 2026, states can opt into CMS’s CGT Access Model, initially focused on sickle cell disease gene therapies. As of July 15, 2025, 33 states + DC + Puerto Rico signed participation agreements—covering roughly 84% of Medicaid beneficiaries with sickle cell. (Source: CMS Innovation Center page & CMS insight note; last checked: Oct 8, 2025.) Centers for Medicare & Medicaid Services+1
What it means: Participating states get federal negotiation support and standardized agreements for these ultra-high-cost therapies, potentially smoothing member access while managing budget risk. (Source: CMS press release; last checked: Oct 8, 2025.) Centers for Medicare & Medicaid Services
Bottom line: If your state joined, access pathways for sickle cell gene therapies should be clearer in 2025–2026.
GLP-1 coverage for obesity vs. diabetes—what states can (and can’t) do
Under federal law, Medicaid must generally cover FDA-approved drugs for medically accepted indications, but weight-loss drugs are among the permissible exclusions. Many states therefore cover GLP-1s for diabetes (e.g., Ozempic/Mounjaro) but restrict or exclude GLP-1s when prescribed for obesity (e.g., Wegovy/Zepbound), unless tied to another FDA-labeled indication such as cardiovascular risk reduction. (Source: KFF explainer; last checked: Oct 8, 2025.) KFF
Recent 2025 moves you should know:
- Massachusetts (MassHealth): As of Jan 1, 2025, Wegovy and Saxenda became non-covered for adult obesity; Zepbound moved to preferred for obesity starting Oct 1, 2024. Pediatric carve-outs remained. (Source: MassHealth pharmacy updates; last checked: Oct 8, 2025.) Mass.gov+1
- Connecticut (DSS): Starting Feb 3, 2025, Wegovy covered for adults with established cardiovascular disease plus obesity/overweight to reduce MACE—not for general weight management. (Source: CT DSS bulletin; last checked: Oct 8, 2025.) Scribd
- California (Medi-Cal Rx): DHCS announced that “drugs used for weight loss” will be excluded from Medi-Cal Rx coverage effective Jan 1, 2026; clinics should plan transitions in late 2025. (Source: DHCS bulletin & CMA summary; last checked: Oct 8, 2025.) medi-calrx.dhcs.ca.gov+1
- Texas (Vendor Drug Program): State rules exclude coverage when the indication is obesity; see GLP-1 criteria and PDL/PA references. (Source: Texas VDP PDL & criteria; last checked: Oct 8, 2025.) Texas Health and Human Services+2txvendordrug.com+2
- New York (NYRx): Uses a statewide PDL with PA for non-preferred agents; check the current PDF for GLP-1 class status. (Source: NYRx PDL; last checked: Oct 8, 2025.) newyork.fhsc.com
Bottom line: In 2025–2026, expect continued divergence: some states narrow obesity coverage (cost control), others allow condition-tethered use (e.g., CVD risk reduction), while diabetes-indicated GLP-1s remain widely available with PA.
State highlights (2025): quick-scan table
| State | 2025 change (headline) | Where to verify |
|---|---|---|
| CA (Medi-Cal Rx) | Weight-loss drugs to be excluded effective Jan 1, 2026; plan transitions late 2025. | DHCS “Upcoming Changes to Medi-Cal Rx” (PDF). Source: DHCS, last checked Oct 8, 2025. medi-calrx.dhcs.ca.gov |
| MA (MassHealth) | Zepbound preferred for obesity (10/1/24); Wegovy/Saxenda non-covered for adults (1/1/25); diabetes GLP-1s remain available. | MassHealth bulletins & therapeutic tables. Source: MassHealth, last checked Oct 8, 2025. Mass.gov+1 |
| CT (DSS) | Wegovy coverage only for CVD risk reduction in adults (not general weight loss) as of 2/3/25. | DSS bulletin (PA criteria). Source: CT DSS, last checked Oct 8, 2025. Scribd |
| TX (VDP) | Obesity indication excluded by rule; see GLP-1 criteria and PDL. | VDP PDL & GLP-1 criteria pages. Source: Texas VDP, last checked Oct 8, 2025. Texas Health and Human Services+1 |
| NY (NYRx) | Centralized statewide PDL; PA required for some GLP-1s; check latest PDF. | NYRx PDP/PDL (PDF). Source: NY DOH, last checked Oct 8, 2025. newyork.fhsc.com |
Note: This is a sampling of recently documented moves. Always click through to the current PDL or DUR bulletin for final criteria.
How to check your state’s latest Medicaid PDL in 60 seconds (checklist)
- Step 1 – Find the official hub: Search
"[State] Medicaid PDL 2025"or go to your Medicaid agency’s Pharmacy page (e.g., NYRx PDL; Texas VDP PDL; Medi-Cal Rx bulletins). (Examples linked above.) newyork.fhsc.com+2txvendordrug.com+2 - Step 2 – Open the class table: Jump to GLP-1 RAs, Anti-Obesity Agents, or the gene therapy bulletin.
- Step 3 – Read the fine print: Look for PA, diagnosis restrictions (ICD-10), step therapy, quantity limits, and age carve-outs. (Example: CA quantity limits bulletin.) medi-calrx.dhcs.ca.gov
- Step 4 – Confirm the date: Use the most recent PDF date (month/year).
- Step 5 – Save the link: Bookmark the page; many states update monthly/quarterly.
Bottom line: Your PDL PDF + the latest DUR/Pharmacy bulletin is the single source of truth for that state.
Gene therapies: where access is expanding in 2025–2026
With the CGT Access Model, participating states can use federal agreements to pay for sickle cell gene therapies on more sustainable terms. As of July 15, 2025, 33 states + DC + PR had signed on, with entry windows from Jan 2025 to Jan 2026. (Source: CMS Innovation Center + CMS insight; last checked: Oct 8, 2025.) Centers for Medicare & Medicaid Services+1
Provider takeaway: If you practice in a participating state, check your plan bulletins for coverage criteria (e.g., genotype, age, prior treatment), centers of excellence, and prior authorization workflows that tie to the CGT model contract your state selected. (Source: CMS CGT announcements; last checked: Oct 8, 2025.) Centers for Medicare & Medicaid Services
Bottom line: Expect clearer, more uniform access for sickle cell gene therapies in participating states during 2025–2026.
Policy mechanics that shape 2025–2026 coverage (practical notes)
- Rebate cap removal (effective 2024) now fully reflected in CMS regs—states may see higher rebate offsets for very old, high-inflation drugs, affecting PDL economics. (Source: Sidley note on MDRP changes; last checked: Oct 8, 2025.) Sidley Austin
- Managed-care contract updates (post-Nov 19, 2025) mean plans will embed MDRP rule language; you may see revised PA forms and data reporting requirements in 2026. (Source: Federal Register & law firm summary; last checked: Oct 8, 2025.) Federal Register+1
Bottom line: Formulary and PA updates in late 2025–2026 often trace back to MDRP compliance and budget math, not clinical reversals.
Buyer’s guide: policy levers & member impact (GLP-1s & CGTs)
| Policy lever | What states/plans do | Member impact | Where it shows up |
|---|---|---|---|
| Exclude obesity indication | Allow GLP-1s for diabetes; block Wegovy/Zepbound for obesity | Obesity Rx denied unless tied to another labeled use (e.g., CVD risk) | PDL class notes; PA forms. KFF + state PDFs. KFF |
| Condition-tethered coverage | Permit Wegovy for CVD risk reduction only | Access for select high-risk adults; general weight loss still excluded | State bulletin (e.g., CT DSS). Scribd |
| Preferred-agent swap | Make one GLP-1 preferred; others non-covered for obesity | Mass switches; cost control; pediatric carve-outs possible | MassHealth updates. Mass.gov |
| Quantity limits / step therapy | Dose-titration schedules; one-carton per 28 days | Prevents stockpiling; slows spend growth | CA QL reminder. medi-calrx.dhcs.ca.gov |
| CGT model participation | Join CMS agreements for sickle cell gene therapy | Clearer access at designated centers; standardized PA | CMS CGT pages. Centers for Medicare & Medicaid Services+1 |
2026 watchlist: what could change next
- Budget pressures: Several states signaled tightening on weight-loss agents into FY2026 (e.g., California’s 2026 exclusion), while others may expand condition-tethered coverage (e.g., CVD risk indications). (Sources: CA DHCS & CMA; last checked: Oct 8, 2025.) medi-calrx.dhcs.ca.gov+1
- Managed-care contracting: Expect PDL and PA alignment as updated contracts hit CY/FY 2026 rating periods under the MDRP rule. (Source: CMS Final Rule; last checked: Oct 8, 2025.) Federal Register
- Cell & gene therapies: More states could join the CGT model by Jan 2026—watch state Medicaid newsrooms for announcements. (Source: CMS CGT page; last checked: Oct 8, 2025.) Centers for Medicare & Medicaid Services
Bottom line: Plan on quarterly formulary checks and mid-year PA tweaks through 2026.
Disclaimer
This article is for information only—not medical, legal, or financial advice. Drug coverage under Medicaid changes frequently. Always confirm with your state Medicaid agency, health plan, or pharmacist before prescribing or filling.
Sources for sensitive facts (all last checked Oct 8, 2025)
- CMS CGT Access Model (states & timing). Centers for Medicare & Medicaid Services+1
- CMS press release on CGT agreements. Centers for Medicare & Medicaid Services
- MDRP Final Rule & effective dates (Federal Register; law firm summaries). Federal Register+2Arnold & Porter+2
- KFF GLP-1 Medicaid coverage explainer. KFF
- California Medi-Cal Rx updates (2025–2026). medi-calrx.dhcs.ca.gov+1
- New York NYRx PDL (Oct 2025). newyork.fhsc.com
- Texas VDP PDL/criteria. txvendordrug.com+3txvendordrug.com+3txvendordrug.com+3
- MassHealth 2024–2025 GLP-1 changes. Mass.gov+1
- Connecticut DSS Wegovy CVD coverage. Scribd
“Bottom line” recap (3–5 takeaways)
- Federal floor is shifting: The MDRP Final Rule and the CGT Access Model shape state coverage and contracting in 2025–2026. Federal Register+1
- GLP-1s for obesity remain state-discretionary: Many states limit or exclude; some allow CVD-tethered use; diabetes GLP-1s generally covered with PA. KFF+1
- Expect quarterly movement: States like CA, MA, CT, TX, NY issued 2025 updates; more will follow into 2026. newyork.fhsc.com+4medi-calrx.dhcs.ca.gov+4Mass.gov+4
- Always verify with the latest PDL PDF or bulletin for your state. newyork.fhsc.com
Next steps:
- Bookmark your state’s PDL and Pharmacy/DUR pages (NYRx, VDP, Medi-Cal Rx, MassHealth, etc.). newyork.fhsc.com+2txvendordrug.com+2
- For CGTs, check whether your state joined the CMS model and follow plan bulletins for PA criteria. Centers for Medicare & Medicaid Services
- Revisit coverage quarterly (or before big prior-auth renewals).
FAQs
1) Which states cover GLP-1s for obesity under Medicaid in 2025?
Coverage varies widely and changes often. Many states exclude weight-loss indications; a few permit condition-tethered use (e.g., CVD risk reduction). Always check your state’s PDL and bulletins. (Source: KFF; state PDFs; last checked Oct 8, 2025.) KFF
2) Does Medicaid have to cover weight-loss drugs?
No. Federal law allows states to exclude weight-loss agents from Medicaid coverage even if covered for other indications like diabetes. (Source: KFF explainer; last checked Oct 8, 2025.) KFF
3) What is the CMS CGT Access Model and why does it matter?
It’s a CMS program helping states buy and manage sickle cell gene therapies via standardized agreements (2025–2026 onboarding). 33 states + DC + PR have signed on. (Source: CMS; last checked Oct 8, 2025.) Centers for Medicare & Medicaid Services+1
4) How will the MDRP Final Rule affect coverage in 2026?
Expect contract updates, PA form changes, and tighter data requirements as the rule flows into managed-care rating periods after Nov 19, 2025. (Source: Federal Register; last checked Oct 8, 2025.) Federal Register
5) Where can I find my state’s official PDL?
On the state Medicaid pharmacy site (e.g., NYRx PDL, Texas VDP, Medi-Cal Rx). Use our checklist to verify class-specific notes and dates. (Sources in article; last checked Oct 8, 2025.) newyork.fhsc.com
6) Are GLP-1s covered for diabetes under Medicaid?
Generally yes (as antidiabetics), subject to PA/step therapy/quantity limits. Policies differ by state and agent. (State PDLs; last checked Oct 8, 2025.) txvendordrug.com
7) What should clinics do if a state changes coverage mid-year?
Check the latest PDL, transition fill policies, and submit updated PA with diagnosis codes that match covered indications. (State bulletins cited above.) Mass.gov