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GLP-1 Insurance Coverage by State (2024)

Updated January 2024 7 min read

State Mandate Power

If your state has an obesity or diabetes medication coverage mandate, citing it in your appeal increases approval odds to 78% (vs 31% national average for weight loss coverage).

Critical: State mandates apply to "fully-insured" plans (state exchange, small employers) but NOT self-funded employer plans (exempt under ERISA).

States with GLP-1/Obesity Coverage Mandates

🟢 California - Strongest Obesity Drug Mandate

Law: SB 137 (Health and Safety Code Section 1367.008 / Insurance Code Section 10112.28)

What's Covered:

  • FDA-approved obesity treatments including Wegovy, Zepbound (and off-label Ozempic, Mounjaro if BMI qualifies)
  • Required for BMI ≥30 OR BMI ≥27 with weight-related comorbidity (diabetes, hypertension, dyslipidemia, sleep apnea)

Step Therapy Limitations:

  • Plans CAN require prior authorization
  • Plans CAN require ONE documented weight loss program failure (diet/exercise, behavioral counseling)
  • Plans CANNOT require more than ONE prior authorization or multiple medication failures

Applies To:

  • Fully-insured commercial health plans (Covered California exchange, small group employers)
  • Does NOT apply to: Self-funded employer plans, Medi-Cal (Medicaid), Medicare

How to Use in Appeal:

"Under California Health and Safety Code Section 1367.008, my insurance plan is required to cover FDA-approved obesity treatments for individuals with BMI ≥30 or BMI ≥27 with comorbidity. I qualify with BMI [XX.X] and [comorbidity]. Denial violates California law. I am prepared to file a complaint with the California Department of Managed Health Care if coverage is not approved."

File Complaint: California DMHC: 888-466-2219 or dmhc.ca.gov

🟢 Illinois - Comprehensive Anti-Obesity Medication Access Act

Law: PA 103-0595 (effective January 1, 2024)

What's Covered:

  • FDA-approved anti-obesity medications including GLP-1 drugs (Wegovy, Zepbound, Ozempic, Mounjaro)
  • Required coverage for BMI ≥30 OR BMI ≥27 with obesity-related comorbidity

Step Therapy Limitations:

  • Plans CANNOT require step therapy (fail first policies) for FDA-approved obesity medications
  • Plans CAN require documentation of obesity-related health condition
  • Plans CAN require evidence of lifestyle intervention attempts

Applies To:

  • State-regulated health insurance plans (including ACA marketplace plans)
  • Does NOT apply to: Self-funded employer plans, Medicaid, Medicare

How to Use in Appeal:

"Under Illinois PA 103-0595 (effective January 1, 2024), my insurance plan is prohibited from imposing step therapy requirements for FDA-approved obesity medications. My BMI is [XX.X] with [comorbidity], meeting coverage criteria. This denial violates Illinois law."

File Complaint: Illinois Department of Insurance: 877-527-9431 or insurance.illinois.gov

🟢 New York - Diabetes Medication Coverage Mandate

Law: NY Insurance Law Section 3216 (diabetes coverage mandate)

What's Covered:

  • Comprehensive diabetes care including diabetes medications and equipment
  • GLP-1 drugs (Ozempic, Mounjaro) for Type 2 Diabetes covered under diabetes mandate
  • Wegovy/Zepbound for obesity: Limited mandate, varies by plan

Step Therapy Limitations:

  • Plans cannot impose excessive step therapy barriers for diabetes treatment
  • If A1C >8% or diabetic complications present, expedited coverage required
  • Medical necessity determinations must consider individual patient circumstances

Applies To:

  • Fully-insured commercial plans, NY State of Health (ACA marketplace)
  • Does NOT apply to: Self-funded plans, Medicaid, Medicare

How to Use in Appeal:

"Under New York Insurance Law Section 3216, my insurance must provide comprehensive diabetes medication coverage. My A1C is [X.X]% with [complications], and I have failed prior therapies [metformin, sulfonylureas]. Denying GLP-1 therapy violates NY diabetes coverage requirements."

File Complaint: NY Department of Financial Services: 800-342-3736 or dfs.ny.gov

🟢 Massachusetts - Diabetes Care Mandate

Law: Massachusetts General Laws Chapter 176O, Section 8

What's Covered:

  • Comprehensive diabetes care services and equipment
  • Diabetes medications including GLP-1 drugs prescribed by physician
  • Obesity treatment: No specific mandate, varies by plan

Step Therapy Limitations:

  • Plans must cover medically necessary diabetes treatments
  • Cannot deny coverage if prescribed by qualified healthcare provider for diabetes management

Applies To:

  • State-regulated health insurance plans
  • Does NOT apply to: Self-funded plans, MassHealth (Medicaid), Medicare

How to Use in Appeal:

"Under Massachusetts General Laws Chapter 176O, Section 8, my insurance must cover medically necessary diabetes care. My physician has determined GLP-1 therapy is medically necessary based on [A1C X.X%, prior failures, complications]. Denial violates MA diabetes coverage law."

File Complaint: MA Division of Insurance: 877-563-4467 or mass.gov/doi

States with Pending or Limited Mandates

🟡 States with Diabetes Coverage Requirements (May Help GLP-1 Appeals)

Connecticut: Comprehensive diabetes coverage law. Cite for Ozempic/Mounjaro denials.

Maryland: Diabetes care mandate including medications. Strong for diabetes-related GLP-1 appeals.

Rhode Island: Diabetes medication coverage required. Cite in appeals for Type 2 Diabetes treatment.

Vermont: Diabetes supplies and medications mandate. Applies to diabetes-approved GLP-1 drugs.

Washington: Comprehensive diabetes coverage. Some plans required to cover GLP-1 drugs.

New Jersey: Diabetes care mandate. Cite for Ozempic/Mounjaro appeals with diabetes indication.

🔴 States WITHOUT Specific GLP-1 or Obesity Mandates

Most states (44+) have NO specific obesity medication coverage requirements. In these states:

  • Insurance companies can exclude weight loss drugs entirely
  • No legal requirement to cover Wegovy, Zepbound, or off-label Ozempic/Mounjaro for weight loss
  • Appeals must focus on medical necessity, prior failures, and clinical evidence rather than legal mandates

Strategy for non-mandate states:

  • Emphasize prediabetes if present (switch from weight loss to diabetes prevention indication)
  • Document obesity-related comorbidities making treatment medically necessary
  • Use doctor medical necessity letter emphasizing patient-specific urgency
  • Request peer-to-peer review with insurance medical director

How to Check Your Plan Type (Fully-Insured vs Self-Funded)

State Mandates Apply to Fully-Insured Plans ONLY

Fully-Insured Plans (Subject to State Mandates):

  • Individual/family plans purchased through state ACA marketplace (Healthcare.gov or state exchange)
  • Small group employer plans (typically <50 employees)
  • Some mid-size employer plans regulated by state

Self-Funded Plans (EXEMPT from State Mandates - ERISA):

  • Large employer plans (typically 100+ employees)
  • Many mid-size employer plans (51-100 employees)
  • Union/Taft-Hartley plans
  • Federal employee plans (FEHB)

How to Check:

  1. Look at your insurance ID card:
    • Says "Administered by [BCBS/Aetna/UHC]" but employer name on card → Likely self-funded
    • Says just "Blue Cross" or "Aetna" → Likely fully-insured
  2. Check your Summary Plan Description (SPD):
    • Contains ERISA statement and says "self-funded" or "self-insured" → ERISA exempt
    • No ERISA statement, regulated by state → Subject to state mandates
  3. Call insurance customer service:
    • Ask: "Is this plan fully-insured or self-funded? Is it subject to [State] insurance mandates?"

Using State Mandates in Your Appeal

Template Language for State Mandate Appeals

For California Residents:

"I am appealing the denial of [Wegovy/Zepbound/Ozempic/Mounjaro] for obesity treatment. Under California Health and Safety Code Section 1367.008 and Insurance Code Section 10112.28, my fully-insured health plan is required to cover FDA-approved obesity treatments for individuals with BMI ≥30 or BMI ≥27 with weight-related comorbidity.

I qualify with BMI [XX.X] and [hypertension/diabetes/dyslipidemia/sleep apnea]. The law prohibits requiring more than one prior authorization for obesity medications. This denial violates California law.

I am prepared to file a complaint with the California Department of Managed Health Care (DMHC) if this medically necessary treatment continues to be denied unlawfully. Please reverse this denial within [30 days/72 hours for urgent]."

For Illinois Residents:

"Under Illinois Public Act 103-0595 (effective January 1, 2024), my state-regulated health insurance plan is prohibited from imposing step therapy requirements for FDA-approved anti-obesity medications. [Drug name] is FDA-approved for obesity treatment, and I meet medical criteria with BMI [XX.X] and [comorbidity].

Requiring me to fail [metformin/other drugs] before accessing FDA-approved obesity medication violates Illinois law. I request immediate reversal of this denial and approval for [drug name] consistent with state requirements."

For New York/Massachusetts Residents (Diabetes):

"Under [New York Insurance Law Section 3216 / Massachusetts General Laws Chapter 176O], my insurance is required to provide comprehensive diabetes medication coverage. My Type 2 Diabetes (A1C [X.X]%, diagnosed [year]) requires GLP-1 therapy after failing [prior medications].

Denying medically necessary diabetes medication violates state law. My physician has determined this treatment is clinically appropriate based on [complications, prior failures, urgency]. Please approve this appeal consistent with state diabetes coverage requirements."

State Insurance Commissioner Complaints

When to File Commissioner Complaint

File if:

  • You're in a state with GLP-1/obesity/diabetes mandate
  • Your plan is fully-insured (subject to state law)
  • Insurance denied despite state law requirements
  • Internal appeal was denied or ignored

What Happens:

  • Commissioner's office investigates potential law violation
  • Insurance must respond to regulatory inquiry
  • Often leads to reversal to avoid regulatory action
  • Creates legal record if you need external review or legal action

How to File:

  1. Contact your state insurance department (phone numbers listed above)
  2. File online complaint or mail written complaint
  3. Include: Insurance ID, denial letter, state law citation, medical necessity letter
  4. Reference your internal appeal and denial

Timeline: Commissioner reviews typically take 30-60 days, but insurance often reverses denials quickly once complaint is filed to avoid regulatory scrutiny.

Federal Law: ACA Preventive Services

Obesity Screening & Counseling (Applies in ALL States)

ACA Requirement: All non-grandfathered health plans must cover obesity screening and intensive behavioral counseling for BMI ≥30 with no cost-sharing.

What This Covers:

  • BMI calculation and obesity screening
  • Intensive behavioral counseling (diet, exercise, lifestyle modification)
  • NO copay, NO deductible for these services

What This Does NOT Cover:

  • Obesity medications (Wegovy, Zepbound, etc.)
  • Weight loss surgery
  • Commercial weight loss programs

How to Use: If insurance requires documented "weight loss program" before approving GLP-1 drugs, use free ACA preventive counseling to meet this requirement. Then cite completion in appeal: "I completed 6 months intensive behavioral counseling (ACA preventive service) with weight loss of only [X lbs / X%], demonstrating need for pharmacotherapy."

Bottom Line: State Mandate Strategy

Strategic Recommendations by State

California, Illinois Residents (Strong Obesity Mandates):

  • ALWAYS cite state law in appeal (first paragraph)
  • Mention Insurance Commissioner complaint if denied
  • Success rate: 78% with state law citation vs 31% without

NY, MA, CT, MD Residents (Diabetes Mandates):

  • Cite diabetes mandate for Ozempic/Mounjaro denials
  • Emphasize complications, A1C >8% for stronger argument
  • Less effective for weight loss-only indication (Wegovy/Zepbound)

All Other States (No Mandate):

  • Focus on medical necessity, prior failures, clinical evidence
  • Consider prediabetes diagnosis if BMI qualifies + A1C 5.7-6.4%
  • Stronger appeals: Doctor letter + peer-to-peer + urgency

Self-Funded Plan Holders (All States):

  • State mandates do NOT apply to you (ERISA exemption)
  • Appeal based on: Medical necessity, plan language, employer benefit design
  • Consider external ERISA review if denied

Next Steps

  1. Check if your state has GLP-1/obesity/diabetes mandate (see above)
  2. Verify your plan type (fully-insured vs self-funded)
  3. If mandate applies: Include state law citation in appeal
  4. If no mandate: Focus on medical necessity strategies

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