Healthy Connections Medicaid does not cover Wegovy or Zepbound for weight loss

Healthy Connections Medicaid stopped covering GLP-1 drugs for weight loss after Dec. 31, 2025, and its pharmacy manual lists weight control products as excluded regardless of circumstance. SCDHHS said Wegovy stays covered for uses other than obesity, such as lowering cardiovascular risk or MASH.1234

SCDHHS applies one set of clinical criteria to the injectable GLP-1 and GLP-1/GIP class, which is now limited to type 2 diabetes. First approvals last 6 months and renewals 1 year.6

• Ozempic and Trulicity (adults): age 18 or older, a documented type 2 diabetes diagnosis, a trial and failure of, intolerance to or contraindication to metformin (90-day claims look-back), a baseline A1c from the previous 3 months, and a dose no higher than the maximum FDA-approved diabetes dose.
• Trulicity (children): the same requirements from age 10.
• Non-preferred drugs (Mounjaro, Victoza, liraglutide, exenatide, Soliqua, Xultophy): the same requirements plus a trial or failure of Ozempic and Trulicity, or a reason they cannot be used.
• Renewal: clinical improvement documented in the previous 3 months (lower A1c, A1c goal reached, or better fasting glucose) and no treatment-limiting side effects.

Coverage for other uses the FDA has approved:

• Wegovy (injection), reduction of the risk of major adverse cardiovascular events (MACE) and MASH; SCDHHS said Wegovy stays covered for indications other than obesity and that members may need a new prior authorization: Covered with prior authorization1

What changed, and when:

CMS BALANCE model: CMS's BALANCE model page names no participating states, and we found no SCDHHS announcement that South Carolina has joined.11

The State Health Plan, run by the South Carolina Public Employee Benefit Authority (PEBA), does not cover prescription drugs used for weight loss. GLP-1s are limited to a 30-day supply per fill, and PEBA added a prior approval step to check that a GLP-1 prescription is for a condition the plan covers.12131415

Pharmacy benefit: CVS Caremark (prescription drugs, since Jan. 1, 2026); BlueCross BlueShield of South Carolina (medical claims).

Marketplace (ACA) plans: South Carolina's essential health benefits benchmark plan, BlueCross BlueShield of South Carolina's Business Blue Complete small-group plan, excludes prescription drugs used for weight control or obesity.18

On the single preferred drug list effective Nov. 1, 2026, which all Medicaid managed care plans and fee-for-service use, Ozempic and Trulicity are the preferred injectable GLP-1s; Mounjaro, Victoza, generic liraglutide and exenatide are non-preferred. Clinical criteria apply to every drug in the class.56

In 2025, Healthy Connections Medicaid paid for 64,970 GLP-1 prescriptions, $64.9 million before rebates: 12 per 1,000 residents, against 32 across the states and DC, 43rd of 51.68 It reimbursed 7 GLP-1 products that year. Every state, ranked.

CMS hides counts under 11 in a quarter, so 49 rows count as zero here and the totals are a floor.

Part D still excludes drugs used for weight loss alone: the Part D drug definition excludes drugs and uses Medicaid may exclude under SSA §1927(d)(2), which lists agents used for weight loss. Part D plans can cover GLP-1s for type 2 diabetes, MACE risk reduction (Wegovy), moderate-to-severe obstructive sleep apnea (Zepbound) and noncirrhotic MASH with fibrosis (Wegovy). For weight loss alone, the Medicare GLP-1 Bridge demonstration (July 1, 2026 – Dec 31, 2027) gives eligible Part D enrollees Foundayo, Wegovy or Zepbound KwikPen for a $50 monthly copay, outside the Part D benefit. The BALANCE Model's Part D component is not launching in 2027.4344343530382333

• Medicare GLP-1 Bridge (demonstration) (active, from 2026-07-01): Runs July 1, 2026 to December 31, 2027 (extended). Outside the Part D benefit: $50 copay per one-month supply (28 or 30 days), Part D deductible does not apply, the copay does not count toward TrOOP, no low-income subsidy. Covers Foundayo, Wegovy (injection or tablet) and Zepbound KwikPen only (not Zepbound single-dose vials or pens). Eligibility: age 18+ and, when starting GLP-1 therapy, BMI ≥35; or BMI ≥30 with heart failure with preserved ejection fraction, uncontrolled hypertension, or CKD stage 3a+; or BMI ≥27 with prediabetes, prior heart attack or stroke, or symptomatic peripheral artery disease. People with type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease are not eligible (their Part D plan may cover GLP-1s for those conditions). Prior authorization required; valid through Dec 31, 2027 unless the patient changes GLP-1s.3031322338394041423736
• BALANCE Model — Medicare Part D component (not launching in 2027; future implementation described by CMS only as 'potential'): Originally announced to launch in Part D in January 2027. CMS's BALANCE page FAQ now refers to 'the BALANCE Model not launching in Medicare in 2027' and extends the Bridge through Dec 31, 2027 to collect data 'ahead of potential implementation of BALANCE in Part D'. No new start date is published.252723

In 2024, Medicare Part D drug plans paid for 427,181 GLP-1 claims from prescribers in South Carolina, $555.5 million in total drug cost.69

The lowest price among the programs that ship to every state is WellMedr: $492 for 12 months ($41 a month); $99 month to month, fees in.73 Includes a sale seen on November 5, 2026; the price returns to the standing price when it ends. The cheapest programs, ranked, or every program, ranked on our score.

Prices are what each program charged at its own checkout, fees in, with the total due for the plan length first. Compounded GLP-1s are prepared by a pharmacy to a prescription, and they are not FDA-approved; the section on compounding explains what that means.

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29 more programs we rank ship to fewer than 50 states, or don’t say how many. We don’t record which states they leave out, so check South Carolina on their sites: Embody, Collective, SnagRx, Enhanced, Direct Meds, Gala Health, GobyMeds, CoreAge Rx, Maximus Tribe, Brightmeds, SkinnyRx, Willow, Strut Health, Enhance MD, LumiMeds, VivioMD, MEDGm, MyDrHank, Zevay, LevelsRx, Hume Care, ReadyRx, Hers, Luvo Health, Remedy Meds, Hims, DudeMeds, G-Plans and Found.

The makers also sell some brand-name GLP-1s for cash, at the same price in every state, with a prescription:

These are standing prices. The Zepbound and Wegovy rankings list each dose and the terms of each offer.

Compounded GLP-1s are prepared by a pharmacy to a prescription. They are not FDA-approved: the FDA doesn’t review their safety, effectiveness or quality before they’re sold, and they are not the same as Wegovy or Zepbound. Formulas can differ from one pharmacy to the next, and some add ingredients such as vitamin B12.7475 Compounding pharmacies are licensed and inspected by state boards of pharmacy; outsourcing facilities (503B) also register with the FDA and are inspected by it. The FDA can issue warning letters when either breaks rules on safety or sterility.

The FDA’s register lists 2 outsourcing facilities (503B) in South Carolina, as of November 6, 2026; 0 show no inspection date and 2 were issued a Form 483.70