Medicaid coverage
Does Texas Medicaid cover Wegovy?
Wegovy (semaglutide) for weight loss / obesity — the Texas Medicaid prior-authorization rule, source-cited.
Texas Medicaid Wegovy PA criteria
GLP-1s for weight loss per se / general obesity are NOT covered (no standalone BMI-only or BMI+comorbidity weight-loss pathway; no oral AOMs on PDL; HB2412/89R did not pass).
BUT Wegovy and Zepbound ARE covered with PA for their non-glycemic FDA indications via dedicated Acentra/HID criteria: Wegovy (rev.
Oct 24 2025) approvable 365 days via a CARDIOVASCULAR pathway (age >=45, CVD diagnosis in last 730 days, AND obesity/overweight diagnosis in last 730 days) OR a MASH pathway (age >=18, noncirrhotic MASH, F2-F3 fibrosis confirmed by biopsy or VCTE/ELF/MRI-PDFF/MRE in last 180 days); Zepbound (rev.
May 8 2026) approvable 180 days for OSA (age >=18, moderate-to-severe OSA, AHI >=15 on PSG or home test, AND obesity diagnosis); both require diet+activity, no MTC/MEN2 (730d), no concurrent GLP-1, with dose limits.
Comorbid obesity is a gating step, not the qualifying indication.
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 →
Note: semaglutide is also sold as Ozempic for type 2 diabetes, which Texas Medicaid evaluates under a separate type 2 diabetes policy (not this one) — see does Texas Medicaid cover Ozempic?. Coverage follows the brand's FDA indication, not the molecule.
Frequently asked
- Does Texas Medicaid cover Wegovy for weight loss / obesity?
- Typically not covered. GLP-1s for weight loss per se / general obesity are NOT covered (no standalone BMI-only or BMI+comorbidity weight-loss pathway; no oral AOMs on PDL; HB2412/89R did not pass). 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 Wegovy for another payer — or draft the PA
Run Wegovy + 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.