# Does Texas Medicaid Cover Wegovy or Zepbound? Exclusions and the Age-45 Rule By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-06 Canonical page: https://glpwatchdog.org/research/texas-medicaid-glp1-coverage > Texas excludes GLP-1s for obesity, yet its criteria guides open three narrow routes: Wegovy for heart disease from age 45, the Wegovy injection for MASH, and Zepbound for sleep apnea. The tests, renewal rules, diabetes coverage and appeal deadlines, from state documents. ## Key points - No Texas Medicaid route approves Wegovy or Zepbound on an obesity diagnosis by itself. - Wegovy's heart route starts at age 45, the entry rule of its trial, though the FDA label has no such floor. - The MASH route is injection only and needs F2 to F3 fibrosis confirmed within 180 days. - Zepbound needs an apnea-hypopnea index of at least 15, plus 5% weight loss at renewal. - Managed-care plans follow the same criteria; plan appeals are due in 60 days, then 120 days for a fair hearing. 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] > **About this article.** This page reads the criteria guides, drug list and formulary published by the Texas Vendor Drug Program as of November 6, 2026. For the federal rule behind all of this, see [why Medicaid treats Ozempic and Wegovy differently](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy). For a state that kept a narrow weight-loss route, see [how Michigan Medicaid applies a BMI of 40](https://glpwatchdog.org/research/michigan-medicaid-glp1-coverage). ## 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? *Texas Medicaid clinical prior authorization routes, from guides dated May 8, 2026* | Route | Who can qualify | Main tests | First approval | Renewal | | --- | --- | --- | --- | --- | | Wegovy injection or tablet, heart | Age 45 or older | A listed cardiovascular diagnosis; an obesity or overweight diagnosis; diet and activity plan | 365 days | 365 days; no weight-loss test | | Wegovy injection, MASH | Age 18 or older | Noncirrhotic MASH; F2 to F3 fibrosis confirmed by biopsy or an accepted test within 180 days; diet and activity plan | 365 days | 365 days; no weight-loss test | | Zepbound, sleep apnea | Age 18 or older | Moderate to severe sleep apnea; apnea-hypopnea index of at least 15 on a sleep study or home test; obesity diagnosis; diet and activity plan | 180 days | 365 days if at least 5% of baseline weight is lost or kept off | | Any of these for obesity alone | None | No approval path | None | None | 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](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) 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](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) for the evidence, and [why the sleep apnea approval changes the Medicaid question in every state](https://glpwatchdog.org/research/does-medicaid-cover-zepbound). ## 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](https://glpwatchdog.org/research/glp1-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](https://glpwatchdog.org/research/phentermine-vs-a-glp1) 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](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them. ## Frequently asked questions ### Does Texas Medicaid cover Wegovy for weight loss? No. Texas rules exclude GLP-1s prescribed for obesity control, and the state's Wegovy criteria have no route that approves on obesity alone. As of November 2026 Wegovy can be covered with prior authorization for heart disease at age 45 or older, or as an injection for the liver disease MASH with F2 to F3 fibrosis. ### Does Texas Medicaid cover Zepbound? Only for moderate to severe sleep apnea in adults, as of November 2026. The request needs an apnea-hypopnea index of at least 15 and an obesity diagnosis. The first approval runs 180 days, and renewal asks for 5% or more off baseline weight, lost or maintained. ### Does Texas Medicaid cover Ozempic? Yes, for type 2 diabetes with prior authorization. Ozempic is a preferred drug on the state list. The criteria ask for a type 2 diabetes diagnosis in the past year plus a history of an oral diabetes drug, the requested drug, or heart or kidney disease. It is not covered for weight loss. ### Does Texas Medicaid cover Saxenda? Saxenda returned no results in the Texas formulary search on November 6, 2026, and state drug-use guidance says its rule excludes Saxenda for obesity control. Generic liraglutide and Victoza appear in the diabetes class instead. ### Why does Texas require age 45 for Wegovy heart coverage? The state's criteria check for cardiovascular disease only from age 45, which matches the entry rule of SELECT, the trial behind that approval. The FDA label itself covers adults with cardiovascular disease plus excess weight and has no higher age floor. The guide does not explain the choice. ## References 1. Texas Prior Authorization Program (Acentra Health for Texas HHSC) Clinical Criteria: Wegovy (Semaglutide), dated May 8, 2026. Texas Vendor Drug Program. 2026. https://paxpress-txpa.acentra.com/wegovy.pdf 2. Texas Prior Authorization Program (Acentra Health for Texas HHSC) Clinical Criteria: Zepbound (Tirzepatide), dated May 8, 2026. Texas Vendor Drug Program. 2026. https://paxpress-txpa.acentra.com/zepbound.pdf 3. Texas Vendor Drug Program Drug Use Criteria: Glucagon-Like Peptide 1 Receptor Agonists, revised October 2024. Texas Health and Human Services. 2024. https://www.hhs.texas.gov/sites/default/files/documents/october-2024-durb-agenda-item10c.pdf 4. State of Texas 1 Tex. Admin. Code §354.1923: Pharmaceutical Services, drug request requirements. Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-354-1923 5. Texas Vendor Drug Program Formulary Drug Search (Wegovy, Zepbound, Saxenda, phentermine and orlistat, queried November 6, 2026). txvendordrug.com. 2026. https://www.txvendordrug.com/searches/formulary-drug-search 6. Centers for Medicare & Medicaid Services Texas State Plan Amendment TX-23-0009 approval, effective January 1, 2023. medicaid.gov. 2023. https://www.medicaid.gov/medicaid/spa/downloads/TX-23-0009.pdf 7. Texas Health and Human Services Texas Medicaid Preferred Drug List, effective July 24, 2026. txvendordrug.com. 2026. https://www.txvendordrug.com/sites/default/files/docs/2026-0724-preferred-drug-list.pdf 8. Texas Prior Authorization Program Clinical Criteria: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists, dated April 3, 2026. Texas Vendor Drug Program. 2026. https://paxpress-txpa.acentra.com/glp_1_receptor_agonists.pdf 9. Texas Vendor Drug Program HHSC Reviews, Updates Clinical Prior Authorization Criteria Guides, May 29, 2026. txvendordrug.com. 2026. https://www.txvendordrug.com/about/news/2026/hhsc-reviews-updates-clinical-prior-authorization-criteria-guides 10. Texas Medicaid & Healthcare Partnership Texas Medicaid Provider Procedures Manual: Outpatient Drug Services Handbook. tmhp.com. 2026. https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_15_Outpatient_Drug/2_15_Outpatient_Drug.htm 11. Texas Health and Human Services Fair and Fraud Hearings. hhs.texas.gov. 2026. https://www.hhs.texas.gov/contact/complaints-appeals/fair-fraud-hearings 12. Texas Health and Human Services Fair and Fraud Hearings Handbook, 1400: Submitting a Fair Hearing Request Summary. hhs.texas.gov. 2026. https://www.hhs.texas.gov/handbooks/fair-fraud-hearings-handbook/1400-submitting-a-fair-hearing-request-summary 13. Code of Federal Regulations 42 CFR §438.402: Statutory basis and general requirements (managed care appeals). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/cfr/text/42/438.402 14. 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 15. United States Code 42 U.S.C. §1396d: Definitions, including early and periodic screening, diagnostic and treatment services. Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396d 16. Novo Nordisk WEGOVY (semaglutide): prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b 17. 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 18. Lincoff AM, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. New England Journal of Medicine. 2023. PMID: 37952131. DOI: 10.1056/NEJMoa2307563. https://pubmed.ncbi.nlm.nih.gov/37952131/ 19. Eli Lilly and Company Zepbound savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings 20. 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 Texas Medicaid Cover Wegovy or Zepbound? Exclusions and the Age-45 Rule", published 2026-11-06. https://glpwatchdog.org/research/texas-medicaid-glp1-coverage Canonical HTML page: https://glpwatchdog.org/research/texas-medicaid-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.