Your doctor prescribed Wegovy or Zepbound for weight loss. You’re on Michigan Medicaid. Will your insurance cover it? Starting this year, probably not—unless you meet strict new criteria buried in Michigan’s bipartisan budget deal.
Bridge Michigan reports the state quietly restricted Medicaid coverage for popular GLP-1 weight loss drugs like Wegovy, Saxenda, and Zepbound. Coverage now requires either a diabetes diagnosis or morbid obesity classification—plus proof other weight loss methods failed.
Translation: Around 2.8 million Michigan Medicaid enrollees face tighter access to medications their doctors may recommend. No grandfather clause. No transition period. The policy took effect with the budget passage.
Who Still Gets Coverage Under New MI Medicaid Rules?
Michigan drew a hard line on eligibility. Two groups qualify:
- Diabetes patients with obesity: You need documented Type 2 diabetes plus a BMI over 30. Prediabetes doesn’t count. Your endocrinologist must submit prior authorization showing blood sugar control issues despite metformin or similar medications.
- Morbidly obese patients: BMI over 40, or BMI over 35 with serious comorbidities like sleep apnea or heart disease. You must document at least 6 months of failed weight loss attempts through diet, exercise, and behavioral counseling before Medicaid approves GLP-1 drugs.
- Bariatric surgery candidates: Coverage extends to patients where weight loss medication prevents higher-cost gastric bypass or sleeve gastrectomy. Your surgeon must document you’re a surgical candidate who could avoid the procedure with pharmaceutical intervention.
The kicker? “Failed interventions” requires detailed records. Verbal claims won’t cut it. Expect your provider to submit food logs, exercise tracking, and documented counseling sessions spanning half a year.
Why Michigan Targeted These Specific Medications
GLP-1 receptor agonists exploded in popularity over the past 3 years. Wegovy, Saxenda, and Zepbound prescriptions surged 300-400% nationally between 2021 and 2024, driven by social media buzz and celebrity endorsements.
The problem for Medicaid? These drugs cost $900-1,300 per month without insurance. With Michigan Medicaid covering roughly 2.8 million residents, unrestricted access could drain tens of millions from the state healthcare budget.
Michigan lawmakers from both parties agreed: prioritize coverage for medical necessity over cosmetic weight loss. The budget language specifically mentions preventing “higher-cost bariatric interventions”—code for gastric bypass surgery that runs $15,000–$25,000 per procedure.
Makes financial sense. But what about the 42% of Americans classified as obese who don’t meet Michigan’s new thresholds?
What This Costs You If Coverage Gets Denied
Let’s talk real numbers. Without Medicaid coverage, expect these monthly costs:
| Medication | Monthly List Price | Manufacturer Savings Card | Your Out-of-Pocket |
|---|---|---|---|
| Wegovy (semaglutide) | $1,349 | $500–$700 discount | $649-$849 |
| Saxenda (liraglutide) | $1,265 | $200–$400 discount | $865-$1,065 |
| Zepbound (tirzepatide) | $1,059 | $550–$650 discount | $409-$509 |
Manufacturer savings cards help, but here’s the catch: they exclude Medicaid patients. Federal anti-kickback laws prohibit drug companies from offering coupons to government insurance beneficiaries. You can’t use both.
That leaves three options if Michigan denies coverage:
- Pay full cash price ($900–$1,300 monthly)
- Switch to private insurance during open enrollment (November 1-January 15 annually)
- Pursue appeal process through Michigan Department of Health and Human Services (90-day timeline)
The Appeal Process: Your Step-by-Step Action Plan
Michigan Medicaid denials aren’t final. You can fight back. Here’s exactly what to do:
Step 1: Request denial letter (within 10 days)
Call Michigan Medicaid customer service at 1-800-642-3195. Ask for written explanation of why coverage was denied. You need this document to appeal.
Step 2: Gather medical documentation (2-4 weeks)
Collect records proving medical necessity:
- BMI measurements over past 12 months
- Documentation of diet/exercise programs with dates and outcomes
- Comorbidity diagnoses (high blood pressure, sleep apnea, prediabetes)
- Photos of food logs or weight tracking apps
- Receipts from weight loss programs like Weight Watchers or Jenny Craig
Step 3: File formal appeal (within 90 days of denial)
Submit to: Michigan Department of Health and Human Services, Office of Recipient Rights. Include all documentation from Step 2 plus a letter from your prescribing physician explaining why this specific medication is medically necessary for you.
Step 4: Request expedited review (if health risk exists)
If your doctor certifies that denial creates immediate health risk, Michigan must decide within 3 business days instead of standard 90 days. Use this for patients with poorly controlled diabetes or pre-surgical weight loss requirements.
Success rate? CMS data shows Medicaid appeals succeed 30-40% of the time when supported by strong medical documentation. Worth pursuing if you’re borderline on eligibility criteria.
What Other States Are Doing (and What It Means for Michigan)
Michigan isn’t alone. At least 14 states restricted GLP-1 coverage through Medicaid in 2024-2025:
| State | Restriction Type | Effective Date |
|---|---|---|
| Michigan | Diabetes + morbid obesity only | October 2025 |
| North Carolina | Prior authorization required | January 2025 |
| Arkansas | BMI 40+ or 35+ with comorbidities | July 2024 |
| Louisiana | Complete coverage removal for weight loss | March 2024 |
Louisiana took the harshest approach—zero Medicaid coverage for weight loss indications, only diabetes. Michigan’s policy sits middle-of-the-pack: stricter than states with basic prior authorization, more generous than complete coverage elimination.
The trend? States are waiting for biosimilar versions (cheaper generics) of semaglutide and tirzepatide. When those hit market in 2026-2027, expect coverage restrictions to ease as prices drop 40-60%.
3 Alternatives Michigan Medicaid Still Covers
If you don’t qualify for GLP-1 drugs, Michigan Medicaid still covers these weight loss treatments:
- Phentermine (generic): $10-30 monthly. Older appetite suppressant, FDA-approved for short-term use (12 weeks). Modest 5-10% weight loss. Michigan covers without prior authorization for BMI 30+.
- Orlistat (Xenical/Alli): $50-100 monthly. Blocks fat absorption. Causes digestive side effects but effective for 5-8% weight loss. Prior authorization not required.
- Bariatric surgery: Gastric bypass, sleeve gastrectomy, or lap-band procedures. Michigan Medicaid covers for BMI 40+ or BMI 35+ with serious comorbidities. Requires 6-month supervised weight loss attempt first.
None match GLP-1 effectiveness (average 15-20% weight loss), but they remain accessible options under current policy.
Frequently Asked Questions
Does Michigan Medicaid cover Ozempic for weight loss?
No. Ozempic (semaglutide) is FDA-approved only for Type 2 diabetes, not weight loss. Michigan Medicaid covers it for diabetes management but explicitly excludes off-label weight loss prescriptions. Wegovy is the weight-loss-approved version of the same drug, now restricted to diabetes patients or those with morbid obesity under the new policy.
Can I switch from Medicaid to private insurance to get coverage?
Yes, during open enrollment (November 1-January 15 annually) or if you have a qualifying life event (job change, marriage, etc.). Private insurance through the Healthcare.gov marketplace often covers GLP-1 drugs with prior authorization, though you’ll pay premiums, deductibles, and copays. Compare total costs: Medicaid with out-of-pocket drug costs versus private insurance premiums plus medication copays.
What BMI qualifies as “morbidly obese” under Michigan’s rules?
BMI of 40 or higher, or BMI of 35-39.9 with serious weight-related health conditions. Those conditions include Type 2 diabetes, severe sleep apnea requiring CPAP, heart disease, or documented mobility impairment. Your doctor must provide diagnosis codes and medical records proving the comorbidity significantly impacts your health. Standard obesity (BMI 30-34.9) without these conditions no longer qualifies.
How long does Michigan’s appeal process take?
Standard appeals take 90 days from filing to decision. Expedited appeals (when denial creates immediate health risk) receive decisions within 3 business days. You must file within 90 days of receiving your denial letter. The state pauses your appeal timeline if they request additional documentation and you don’t respond within 30 days. Roughly 35% of Medicaid prescription appeals succeed when supported by comprehensive medical records.
Will Michigan’s policy change if drug prices drop?
Likely yes. Biosimilar versions of semaglutide are expected in 2026-2027, potentially dropping costs 40-60%. State budget analysts typically review Medicaid drug coverage annually. If GLP-1 drugs become affordable enough that cost-per-patient drops below bariatric surgery expenses, Michigan may expand eligibility criteria. Monitor Michigan Department of Health and Human Services announcements each summer during budget negotiations for policy updates.
Bottom Line: Know Your Options Before Your Next Refill
Michigan’s policy shift hits hardest if you’re already taking these medications. No grandfather clause means current patients face the same restrictions as new patients. Check your eligibility before your next refill—don’t assume coverage will continue.
If you qualify under the new criteria, expect additional paperwork. Your doctor will need to submit prior authorization documenting your diabetes diagnosis or morbid obesity classification, plus proof you tried other weight loss methods for at least 6 months.
If you don’t qualify, start your appeal immediately. The 90-day window starts ticking from your denial date. Waiting reduces your chances of success and leaves you paying out-of-pocket longer.
The broader trend? States are balancing Medicaid budgets by restricting expensive specialty drugs. Michigan’s approach represents a compromise: coverage for medical necessity, restrictions for cosmetic use. Whether that’s fair depends on where you draw the line between health need and personal choice.
Either way, 2.8 million Michigan Medicaid enrollees now operate under tighter rules. Make sure you know where you stand before your pharmacy rejects your prescription.