OBJECTIVES: More than one third of adults in the U.S. are considered obese (body mass index ≥ 30kg/m). Because of their relatively low socioeconomic status, the Medicaid population is disproportionately affected by obesity. The objective was to compare the utilization of and spending on anti-obesity medication, specifically orlistat (amphetamine-based weight-loss drugs were highly restricted by Medicaid because of their potential for abuse), by state Medicaid programs from 1999-2013. Orlistat, approved by the FDA in April 1999, is a gastric and pancreatic lipase inhibitor that reduces dietary fat absorption. METHODS: Using the individual state files for Medicaid outpatient drug utilization maintained by the Centers for Medicare and Medicaid Services, quarterly utilization and (pre-rebate) expenditure data from 1999-2013 were extracted for all branded and generic orlistat prescriptions for Medicaid beneficiaries.  Descriptive statistics were computed. RESULTS: In 1999, North Carolina reimbursed 5,242 prescriptions; Louisiana 3,712 prescriptions; and Wisconsin 1,460. Subsequently, several other states, such as California, Connecticut, Kentucky, Minnesota, New Jersey, and Pennsylvania came on board with a fairly large number of prescriptions reimbursed (6,041 in California in 2003).  In other states, like Ohio and New York, no orlistat prescriptions were reimbursed until the last years of the study, most likely representing a policy shift.  In 2001,when Medicaid utilization was at its peak, a total of 87,811 prescriptions were reimbursed across the country.  By 2013, due to several factors including an over-the-counter version of orlistat approved by the FDA in 2010 and a loss in popularity due to gastrointestinal side effects, only 3,424 prescriptions were reimbursed.  Reimbursement per prescription varied by state; in 2001, the national average was $107. CONCLUSIONS: Despite an obesity epidemic, very few states reimbursed pharmacies for weight-loss medications, including orlistat. Understanding the different decisions that the states made with respect to weight-loss pharmacotherapy is a goal for future research.