Utilization of and gross spending on anti-obesity GLP-1 receptor agonists in state Medicaid programs, 2021 to 2026: a brand-level analysis of State Drug Utilization Data

Abstract Glucagon-like peptide-1 (GLP-1) receptor agonists marketed for chronic weight management are an optional Medicaid benefit that most states have not covered, but indications approved in 2024 and 2025 for cardiovascular risk reduction, obstructive sleep apnea, and steatohepatitis fall outside the statutory weight-loss exclusion. Because the leading molecules carry separate brand names and National Drug Codes (NDCs) for obesity and for diabetes, molecule-level data cannot isolate use of the obesity-indicated products. Using Centers for Medicare & Medicaid Services State Drug Utilization Data, we built a state by quarter by brand panel for the 50 states, the District of Columbia, and Puerto Rico from 2021 through the first quarter of 2026. Wegovy, Zepbound, Saxenda, weight-management liraglutide generics, and orforglipron were identified by NDC; diabetes-indicated brands were excluded. Outcomes were prescriptions, gross reimbursement before rebates, and the number of states reporting utilization; suppressed records were not imputed. Prescriptions rose from 20,449 in 2021 to 3,745,987 in 2025, and gross reimbursement from $24.7 million to $4.44 billion. Although 12 to 13 states formally covered these drugs for obesity in 2024, 41 states reported Wegovy utilization in the fourth quarter of 2024 and 44 reported Zepbound utilization in the fourth quarter of 2025, most of the increase following the cardiovascular and sleep apnea approvals. California accounted for 47% of 2025 gross reimbursement and the five highest-spending states for 81%. Where states added, suspended, restored, or ended obesity coverage, utilization moved in the same direction within one or two quarters; in the first quarter of 2026, prescriptions fell 80% in the four states that ended coverage. Gross reimbursement overstates net state cost, which depends on confidential rebates and federal matching. Medicaid use of these brands extends well beyond states with formal obesity coverage; the public panel provides a baseline for monitoring future changes.