Medicaid coverage
Does Texas Medicaid cover Rybelsus?
Rybelsus (semaglutide (oral)) for type 2 diabetes — the Texas Medicaid prior-authorization rule, source-cited.
Texas Medicaid Rybelsus PA criteria
Per Texas PA Program Clinical Criteria - GLP-1 Receptor Agonists (HID, rev.
Sept 12 2025).
Age >=18 (or >=10 for Bydureon BCise/Trulicity/Victoza); type 2 diabetes diagnosis in last 365 days; history of an oral antidiabetic agent for 14 CONSECUTIVE days in the last 365 days (if none, approves on >=14-day history of the requested GLP-1, else for Ozempic/Trulicity/Victoza only proceeds to the ASCVD/HF/CKD carve-out requiring such a diagnosis in last 365 days); deny on history of ESRD/pancreatitis/gastroparesis/MTC/MEN2 (730 days); HbA1c test in last 180 days; no concurrent GLP-1; approval/reauth 365 days.
PDL preferred (Ozempic, Trulicity, Victoza, Rybelsus, Byetta) vs non-preferred (Mounjaro, Bydureon BCise, exenatide, liraglutide) is medium-confidence (PDL not directly retrievable).
Uniform statewide PDL binds FFS + STAR/STAR+PLUS MCOs.
Source: Texas PA Program Clinical Criteria (Acentra/HID): GLP-1 Receptor Agonists (Sept 12 2025), Wegovy (Oct 24 2025), Zepbound (May 8 2026). View cited GLP-1 policy reference →
Frequently asked
- Does Texas Medicaid cover Rybelsus for type 2 diabetes?
- Covered with prior authorization. Per Texas PA Program Clinical Criteria - GLP-1 Receptor Agonists (HID, rev. See the full source-cited criteria above. Per Texas PA Program Clinical Criteria (Acentra/HID): GLP-1 Receptor Agonists (Sept 12 2025), Wegovy (Oct 24 2025), Zepbound (May 8 2026), as of 2025-2026 (diabetes criteria rev. Sept 12 2025; Wegovy rev. Oct 24 2025; Zepbound rev. May 8 2026) — confirm the member's current plan policy.
d3rx does not hold plan-specific pharmacy formularies or PBM prior-auth grids, so it cannot confirm a particular plan's GLP-1 coverage, tier, or PA criteria. The guidance below is the general, source-cited rule; confirm the specific plan's pharmacy formulary / PA policy for a binding answer.
Check Rybelsus for another payer — or draft the PA
Run Rybelsus + any payer in the GLP-1 PA lookup, or have Ask D3 draft a Texas Medicaid-ready prior-authorization request with the right criteria and codes — free, no signup.