Does Texas Medicaid Cover Wegovy or Zepbound? Exclusions and the Age-45 Rule

Not for weight loss. Texas Medicaid’s rules exclude GLP-1s prescribed for obesity control, and no path in its criteria approves Wegovy or Zepbound on an obesity diagnosis alone.^[1][2][3] As of November 2026 the state does cover them with clinical prior authorization for three narrower uses: Wegovy for heart disease at age 45 or older, the Wegovy injection for the liver disease MASH, and Zepbound for moderate to severe sleep apnea.^[1][2]

Why doesn't Texas Medicaid pay for weight loss?

States may leave weight-loss drugs out of Medicaid under federal law.^[14] Texas’s rule lists “obesity control drugs” among the classes the state may refuse, and its own drug-use guidance says that rule excludes Saxenda and Wegovy for obesity control.^[3][4] Saxenda returned no results in the state’s formulary search on November 6, 2026.^[5]

Wegovy and Zepbound are different because they now hold other approvals. The formulary lists Wegovy pens from December 27, 2024 and Zepbound pens from November 4, 2025, each flagged for clinical prior authorization.^[5] Being on the formulary does not change the exclusion. It means a request can be approved if it fits one of the decision trees below. Managed-care plans had to adopt the current Wegovy and Zepbound criteria by June 1, 2026, the same date as fee-for-service.^[9]

When will Texas Medicaid approve Wegovy or Zepbound?

Every route also screens out anyone with medullary thyroid cancer or MEN 2 in their past, and anyone taking a second GLP-1.^[1][2] Wegovy is capped at four pens per 28 days or one tablet a day, and Zepbound at 15 mg a week.^[1][2]

Does Texas Medicaid cover Wegovy for heart disease?

Yes, if you are at least 45. The state checks claims history for a cardiovascular code and an obesity or overweight code.^[1] The cardiovascular list is broad: heart attack, unstable angina, chronic ischemic heart disease, heart failure, ischemic stroke, narrowed arteries feeding the brain, and atherosclerosis in the limbs.^[1] The weight list starts at overweight and a BMI of 27, and the guide sets no higher threshold.^[1]

The age line deserves a close look. Wegovy’s label speaks of adults who have cardiovascular disease plus excess weight, and it sets no minimum age beyond adulthood.^[16] Texas’s 45 matches the entry rule of SELECT, the randomized trial behind that approval.^[18] The result is that a 40-year-old with a prior heart attack is sent straight to the MASH question on the injection and denied if there is no MASH. A tablet request under 45 is denied outright.^[1] Someone in that spot can still appeal, pointing to the label, though nothing in the guide promises an exception.

Does Texas Medicaid cover Wegovy for MASH?

Only the injection, which matches the label.^[1][16] The request needs noncirrhotic MASH with fibrosis at stage F2 or F3, confirmed in the last 180 days by a liver biopsy or by one of the tests the guide names: elastography (including FibroScan), the ELF blood test, MRI-PDFF or magnetic resonance elastography.^[1] This route has no obesity question. The tight clock is the part most likely to trip a file, so an older biopsy may need a fresh test. Our guide to GLP-1s and fatty liver covers what the trial showed.

Does Texas Medicaid cover Zepbound for sleep apnea?

Yes, with prior authorization, for adults who meet the test.^[2] The label’s use is moderate to severe sleep apnea in adults with obesity, and the state turns that into hard checks: an apnea-hypopnea index of at least 15 and an obesity code, whose list begins at a BMI of 30 and leaves out the overweight code.^[2][17] The guide does not ask for a trial of CPAP. Zepbound is also the one route with a weight test at renewal, so the 180-day first approval leads to a check for 5% weight loss, kept off.^[2] See Zepbound for sleep apnea for the evidence, and why the sleep apnea approval changes the Medicaid question in every state.

Does Texas Medicaid cover Ozempic and other diabetes GLP-1s?

Yes, for type 2 diabetes. The preferred drug list effective July 24, 2026 prefers Byetta, Ozempic, Trulicity and Victoza, and lists Bydureon BCise, exenatide, generic liraglutide, Mounjaro and Rybelsus as non-preferred.^[7] A clinical prior authorization covers the whole class on top of that.^[7] It looks for a type 2 diabetes diagnosis in the past year, plus 14 straight days of either an oral diabetes drug or the requested drug, and an HbA1c test in the last 180 days. Without that drug history, adults can qualify for Ozempic, Trulicity or Victoza through a record of atherosclerotic heart disease, heart failure or chronic kidney disease.^[8] Trulicity, Victoza and Bydureon BCise reach down to age 10.^[8] Without a type 2 diabetes diagnosis, an Ozempic request is denied.

Does the rule change with a managed care plan, or for children?

Most of the program’s drug rules travel with you. Texas plans are required to adhere to the preferred drug list and had to adopt these criteria, so changing plans should not open a route for obesity.^[9][10] Separate from that, CHIP has no preferred drug list. The formulary shows CHIP dates for Zepbound and Wegovy tablets but not for the older Wegovy pens.^[5][10]

Wegovy’s label reaches down to age 12 for obesity, while the Texas Wegovy and Zepbound guides end at a denial under 18.^[1][2][16] Federal child-health rules require Medicaid to provide necessary treatment to people under 21 whether or not the state plan covers it.^[15] We found no Texas document that applies that duty to these drugs, so a family should ask for a medical necessity review by name and appeal a flat refusal.

How do you appeal a denial in Texas?

• Managed care. You have 60 calendar days from the notice to appeal to the plan.^[13] After the plan’s final decision, you have 120 days to ask the state for a fair hearing.^[12]
• Fee-for-service. A fair hearing request is generally due within 90 days of the case action or the effective date on the notice.^[11]
• Late requests. The state reviews them for good cause, so a missed date is worth raising anyway.^[11]
• While you wait. For a covered use, Texas pharmacists can provide a 72-hour emergency supply when a prior authorization is not available.^[10]

An appeal has something to work with when the dispute is about a covered use, such as a missing sleep study result. It has much less when the only diagnosis is obesity. Our walkthrough of prior authorization and appeals shows what to put in the file. A prescriber should not add a diagnosis you do not have, which is fraud.

What are the options if you don't qualify?

Older drugs are one place to ask. On November 6, 2026 the formulary search showed phentermine and orlistat with no clinical or preferred-list prior authorization flag, and the state plan says selected weight-loss agents are covered as listed on its website.^[5][6] Ask your pharmacist or plan to confirm before relying on that. Our comparison of phentermine and a GLP-1 sets out how much less they do.

Cash is the other route. Lilly’s savings card for insured patients excludes Medicaid enrollees.^[19] Self-pay prices in the figures we track are $349 a month for most Wegovy pen doses from Novo Nordisk. Lilly’s Zepbound KwikPen or vial costs $299 at the starting dose, $399 at 5 mg and $449 at 7.5 mg and up when each refill comes within 45 days.^[19][20] Check each offer’s terms for limits on government-program members. The guide to the lowest GLP-1 prices without insurance compares them.