Medicaid Obesity Coverage Linked To Substitution From Diabetes-Labeled to Obesity-Labeled GLP-1 Drugs

State Medicaid coverage of obesity-labeled glucagon-like peptide-1 receptor agonists (GLP-1 RAs) was associated with increased use of these agents, and the findings suggest possible substitution from diabetes-labeled versions, according to a cross-sectional study published in JAMA Health Forum.

Obesity-labeled and diabetes-labeled GLP-1 RAs have identical active ingredients, and all states cover the diabetes-labeled versions, but fewer than one-third of states cover GLP-1 RAs for obesity through Medicaid, the authors noted. Using Medicaid State Drug Utilization Data from 2021 to 2024, the investigators applied a synthetic difference-in-differences approach to compare 9 states that began covering obesity-labeled GLP-1 RAs with 36 control states.

Coverage was associated with a mean increase of 6.48 obesity-labeled GLP-1 RA prescriptions per 1000 beneficiaries (95% CI, 3.98-8.98). Changes in total GLP-1 RA prescriptions (4.17 per 1000; 95% CI, −0.33 to 8.67) and diabetes-labeled prescriptions (−2.16 per 1000; 95% CI, −5.24 to 0.92) were not statistically significant. Increases in obesity-labeled use came primarily from semaglutide (Wegovy, Novo Nordisk) and tirzepatide (Zepbound, Eli Lilly).

In states with prior authorization requirements more restrictive than the FDA label, diabetes-labeled GLP-1 RA use decreased by 3.02 prescriptions per 1000 beneficiaries relative to controls (95% CI, −5.69 to −0.36). The authors noted that diabetes-labeled use increased in all states and that the negative estimates reflect slower growth rather than an absolute reduction.

The authors noted that the study is ecological and does not directly demonstrate whether patients switched between label indications, that reimbursement estimates do not account for Medicaid rebates, and that drug shortages during the study period could have introduced confounding. They concluded that substitution effects are possible, varying by state coverage policy, and could affect the impact of coverage decisions on total GLP-1 RA utilization and cost.

Source: Khanna R, Wang MC, Venkataramani AS. GLP-1 receptor agonist coverage for obesity in Medicaid and total GLP-1 receptor agonist utilization. JAMA Health Forum. 2026;7(9):e263353. doi:10.1001/jamahealthforum.2026.3353