# Does the Oregon Health Plan Cover Wegovy or Zepbound? OHP's 2026 GLP-1 Rules By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-07 Canonical page: https://glpwatchdog.org/research/oregon-health-plan-glp1-coverage > OHP refuses GLP-1s for adult weight loss, but its October 2026 criteria open Wegovy for heart disease or MASH, plus Zepbound for sleep apnea, after a weight plan and a diabetes screen. Members under 21 can get a weight drug reviewed case by case. Criteria, renewals and appeals. ## Key points - Adults get no coverage for weight loss alone; Foundayo, Qsymia and Contrave fall under the same rule. - Wegovy for heart disease needs a BMI from 25 with a related condition, a provider-run weight plan for 3 of 6 months and a diabetes screen. - Zepbound for sleep apnea needs an AHI from 15 and a BMI from 30, with no CPAP trial. - Renewals for the heart and sleep apnea routes require at least a 5% drop in BMI. - Members eligible for EPSDT, mostly those under 21, can be approved for a weight drug cleared for their age. Not for adults trying to lose weight. As of November 2026, the Oregon Health Plan covers Wegovy only for adults with established heart disease or the liver disease MASH, and Zepbound only for adults with obesity and moderate to severe sleep apnea, each with prior authorization.[1] Members under 21, who fall under the federal child-health benefit, are the exception: OHP will review a weight drug approved for their age case by case.[1] > **About this article.** This page reads the Oregon Health Authority’s Medicaid PA Criteria Guide dated October 1, 2026, the pharmacy quick reference effective January 1, 2026, and OHA’s appeals page, as they stood on November 1 and 2, 2026. The guide governs open card (fee-for-service) prescriptions; members of a coordinated care organization follow their CCO’s prior authorization process, and we did not read any CCO’s criteria. To compare states, use the [state Medicaid GLP-1 checker](https://glpwatchdog.org/tools/state-medicaid-glp1-checker). ## Does the Oregon Health Plan cover Wegovy for weight loss? Not for adults. The criteria say drugs prescribed only for overweight or obesity “are NOT currently covered,” and a request with no other approved use ends in a denial stating that OHP does not cover these drugs for adults when they are used for weight loss.[1] The guide spells out each drug: semaglutide needs heart disease, MASH or type 2 diabetes; tirzepatide needs sleep apnea or type 2 diabetes; liraglutide needs type 2 diabetes or MASH.[1] Under federal law, a state may make this choice.[4] Our explainer on [why Medicaid separates Ozempic from Wegovy](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy) covers the federal side, and the [Medicaid coverage hub](https://glpwatchdog.org/insurance/medicaid) compares states. Foundayo, Qsymia, Contrave and orlistat appear in the guide’s table of FDA-approved weight drugs, but none has an adult indication on the covered list, so adult requests for them fall to the same denial.[1] ## Which GLP-1 uses does OHP cover for adults? *Oregon Health Plan adult GLP-1 routes outside diabetes, from the PA Criteria Guide dated October 1, 2026* | Use | Drug | Main requirements | First approval | | --- | --- | --- | --- | | Weight loss alone | Any | Not covered | None | | Established heart disease | Semaglutide (Wegovy injection or tablets) | Past heart attack, stroke or leg artery disease with symptoms; BMI 30 or more, or 25 or more with a related condition; provider-run weight plan for 3 of the past 6 months; diabetes screen | Up to 6 months | | MASH with stage 2 or 3 fibrosis | Semaglutide injection, or liraglutide | Biopsy, or a set of exclusions and risk factors; fibrosis test in the past 24 months; liver or GI specialist | Up to 6 months | | Moderate to severe sleep apnea | Tirzepatide (Zepbound) | AHI of 15 or more; BMI 30 or more; weight plan for 3 of the past 6 months; diabetes screen | Up to 6 months | Three steps apply to the heart and sleep apnea routes before the drug question is reached. The BMI must be at least 30, or at least 25 with a related condition such as diabetes, high blood pressure, abnormal cholesterol, fatty liver disease or heart disease, so someone with heart disease meets the 25 line.[1] The patient must be in a lifestyle program and must have tried a weight plan run by a health care provider, such as diet and exercise coaching or nutrition counseling, for at least three of the previous six months.[1] The chart must also show either a type 2 diabetes diagnosis or a diabetes screen in the past year that came back negative, such as an A1c under 6.5%.[1] ## What does OHP require for Wegovy and heart disease? Established cardiovascular disease, with a past heart attack, a stroke, or leg artery disease with symptoms given as examples.[1] The guide sets no age minimum and names no cardiologist. Unlike some states, it covers the Wegovy tablets as well as the injection on this route.[1] The label covers adults with established heart disease and either obesity or overweight.[6] After the first six months, renewal requires that the patient has lost, or kept off, at least 5% of BMI, has stayed on the drug and is still in the weight plan; renewals then run up to 12 months.[1] The 5% bar can catch people out: the heart route is meant to lower heart risk, but the renewal is measured on weight. ## Does the Oregon Health Plan cover Wegovy for fatty liver disease? Yes, for MASH with stage 2 or 3 fibrosis in adults, using the Wegovy injection; the guide also lists liraglutide for this use.[1] The diagnosis can rest on a liver biopsy. Without one, the file must show no significant alcohol use in the past two years, no viral hepatitis, other causes of fatty liver ruled out, and at least three of five metabolic risk factors, such as excess weight, high blood pressure or type 2 diabetes.[1] A biopsy, liver stiffness scan, MR elastography or ELF test from the past 24 months must show the fibrosis stage, and a hepatologist or gastroenterologist must order or consult.[1] The MASH route skips the BMI and weight plan steps.[1] Renewal needs proof the patient is taking the drug, a liver test within the past year, and no sign of cirrhosis or worsening fibrosis.[1] The FDA approved this use on an accelerated basis.[6] Our page on [semaglutide for MASH](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) covers the trial behind it. ## Does OHP cover Zepbound for sleep apnea? Yes, when an adult whose BMI is 30 or higher has moderate to severe obstructive sleep apnea, defined as an AHI of 15 or more events an hour.[1] The criteria set no CPAP trial and name no sleep specialist, which keeps them close to the label.[1][5] The BMI, weight plan and diabetes screen steps above still apply, and renewal needs the same 5% BMI loss as the heart route.[1] Our guide to [Zepbound for sleep apnea](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) covers the trials. ## Can a teenager on OHP get Wegovy for weight loss? Possibly. This is where Oregon differs from most states. OHP reviews requests case by case for members eligible for EPSDT, the federal child-health benefit, which in Oregon means people under 21 and some youth with special health care needs who turn 21 or 22 in 2026.[1] The drug must be FDA-approved for the patient’s age; the guide lists Wegovy injection, Saxenda, Qsymia and orlistat from age 12.[1] Wegovy’s label covers obesity from age 12.[6] For a teen, the BMI test compares the teen with the 95th percentile on growth charts for the same age and sex, and the patient must be in a lifestyle program.[1] A teen with a related condition, such as high blood pressure, abnormal cholesterol, fatty liver disease, depression or sleep apnea, can be approved for six months; one without such a condition needs three months of a provider-run weight plan first.[1] Renewal under 18 asks for at least a 1% drop in BMI.[1] Because the rule is written by age rather than by diagnosis, the same flow appears to reach EPSDT-eligible members aged 18 to 20 for a drug approved in adults, such as Zepbound; ask the reviewer to confirm. Our review of [GLP-1 drugs in teenagers](https://glpwatchdog.org/research/glp1-drugs-in-teenagers) covers the evidence. ## Does OHP cover Ozempic for diabetes? Yes. For type 2 diabetes, preferred GLP-1 products need no prior authorization when used as second-line treatment with metformin; non-preferred ones need a failed metformin trial or a reason metformin cannot be used, and approvals last up to 12 months.[1] The guide sends heart, MASH and sleep apnea requests to the weight management criteria instead.[1] ## How do you request prior authorization or appeal with OHP? Open card prescriptions go through the Oregon Pharmacy Call Center at 888-202-2126, fax 888-346-0178.[2] CCO members follow their CCO’s process, since the CCO pays for most drugs for its members.[1][2] A CCO member appeals to the CCO first, by phone or in writing; the CCO must receive the appeal within 60 days of the date on the denial notice.[3] If the CCO keeps the denial, the member can ask OHA for a hearing within 120 days, counted from the date printed on the CCO’s Notice of Appeal Resolution.[3] An urgent appeal is decided in 72 hours.[3] A denial for a missing weight plan record or diabetes screen is usually fixed by resubmitting. Our guide to [prior authorization and appeals](https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals) covers what to include. ## What are the options if OHP will not pay? Paying cash, without the Zepbound copay card, whose terms exclude Medicaid members.[7] In the prices we track, Novo Nordisk sells most Wegovy pen doses for $349 a month, and Lilly’s Zepbound costs $299 at the starting dose, $399 at 5 mg and $449 at higher doses refilled on time.[7][8] Our list of the [cheapest GLP-1 options without insurance](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them. ## Frequently asked questions ### Does the Oregon Health Plan cover Wegovy? For adults, only for established heart disease or MASH with stage 2 or 3 fibrosis, with prior authorization. As of November 2026, OHP does not cover Wegovy for adults when the only goal is weight loss. ### Does OHP cover Zepbound? For adults with obesity and moderate to severe sleep apnea, meaning an AHI from 15 up and a BMI from 30 up. There is no CPAP step, but the patient must have tried a provider-run weight plan for three of the past six months. ### Does the Oregon Health Plan cover weight-loss drugs for teenagers? Case by case. Members under 21 are eligible for EPSDT review, and OHP can approve a weight drug the FDA has approved for their age, such as Wegovy from 12, for six months when the criteria are met. ### Does OHP cover Ozempic? Yes, for type 2 diabetes. Preferred GLP-1 products need no prior authorization as second-line treatment with metformin; non-preferred ones need a failed metformin trial or a reason it cannot be used. ### Does OHP cover Foundayo or Qsymia for weight loss? Not for adults. Both are listed among FDA-approved weight drugs, but OHP covers adult weight drugs only for heart disease, MASH or sleep apnea. Qsymia can be reviewed for EPSDT-eligible members aged 12 and older. ### How long do I have to appeal an OHP denial? File with your CCO so it arrives within 60 days of the denial notice's date. If the CCO upholds the denial, you have 120 days from its Notice of Appeal Resolution to ask OHA for a hearing. ## References 1. Oregon Health Authority, Health Systems Division Oregon Medicaid PA Criteria Guide, October 1, 2026 (Weight Management Drugs; GLP-1 and GIP receptor agonists; EPSDT review). oregon.gov. 2026. https://www.oregon.gov/oha/HSD/OHP/Tools/Oregon%20Medicaid%20PA%20Criteria%20Guide%20-%20October%201-2026.pdf 2. Oregon Health Authority Oregon Medicaid Pharmacy Quick Reference (effective January 1, 2026). oregon.gov. 2026. https://www.oregon.gov/oha/HSD/OHP/Tools/Oregon%20Medicaid%20Pharmacy%20Quick%20Reference.pdf 3. Oregon Health Authority Oregon Health Plan: Appeals and Hearings. oregon.gov. 2026. https://www.oregon.gov/oha/HSD/OHP/Pages/Appeals-Hearings.aspx 4. United States Code 42 U.S.C. §1396r-8: Payment for covered outpatient drugs (Social Security Act §1927). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396r-8 5. Eli Lilly and Company ZEPBOUND (tirzepatide) injection: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b 6. Novo Nordisk WEGOVY (semaglutide) injection and tablets: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b 7. Eli Lilly and Company Zepbound savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings 8. Novo Nordisk Wegovy savings offer. novocare.com. 2026. https://www.novocare.com/obesity/products/wegovy/savings-offer.html --- Cite as: GLP Watchdog, Nora Bissett, "Does the Oregon Health Plan Cover Wegovy or Zepbound? OHP's 2026 GLP-1 Rules", published 2026-11-07. https://glpwatchdog.org/research/oregon-health-plan-glp1-coverage Canonical HTML page: https://glpwatchdog.org/research/oregon-health-plan-glp1-coverage Medical disclaimer: Nothing here is medical advice. We report on this subject; we do not treat anyone. Whether to begin a medication, supplement, or treatment, whether to adjust it, and whether to stop are questions for a clinician licensed to answer them, who knows your history.