Does Texas Medicaid cover GLP-1s for weight loss?
Does Texas Medicaid cover GLP-1s for weight loss?
Texas Medicaid covers a weight-loss drug but not a GLP-1 on that indication. Coverage for type 2 diabetes, for Wegovy's cardiovascular indication and for Zepbound in moderate to severe sleep apnea is required of every state program regardless. So the practical question at a denial is rarely "does my state cover it" but "which indication am I being prescribed this under". On BMI: Texas publishes no threshold for obesity itself, because obesity alone is never an approvable reason: the decision tree denies at step two without a cardiovascular diagnosis. The qualifying-diagnosis list at step three does set a floor — Table 3 takes the obesity and overweight codes and the BMI codes from Z68.27, a BMI of 27.0, upwards. Those criteria are quoted from Texas Prior Authorization Program Clinical Criteria — Wegovy, read directly rather than summarized from an aggregator. The status above is read from the state's own published document rather than a national summary.
What Texas will approve, and on what
- On BMI
- Texas publishes no threshold for obesity itself, because obesity alone is never an approvable reason: the decision tree denies at step two without a cardiovascular diagnosis. The qualifying-diagnosis list at step three does set a floor — Table 3 takes the obesity and overweight codes and the BMI codes from Z68.27, a BMI of 27.0, upwards.
- What it takes
- Wegovy is approved only with a cardiovascular-disease diagnosis recorded in the past 730 days alongside a diagnosis of obesity or overweight, no concurrent GLP-1, and no history of pancreatitis, gastroparesis, medullary thyroid carcinoma or MEN 2 in the past 180 days. An approval runs 365 days.
Texas's current criteria, in force since 30 July 2026, approve Wegovy on two routes: documented cardiovascular disease with a diagnosis of obesity or overweight, for members 45 or older, or non-cirrhotic MASH with F2 to F3 liver fibrosis confirmed by biopsy or a non-invasive test within 180 days, for adults on the injection. Obesity alone is still denied, so in Texas the question is whether heart or liver disease is documented, not your BMI.
Both tools fill from these criteria rather than from a template — a prior authorization for Texas, or a letter appealing a denial. If the plan is not Medicaid, the 9 insurer and program pages cover a different set of rules.
Whatever Texas decides about obesity, federal law still makes it cover a GLP-1 prescribed for type 2 diabetes, Wegovy for cardiovascular risk reduction and Zepbound for obstructive sleep apnea — the exclusion is written against the use, not the drug. Which approval a weight-loss exclusion cannot reach, and what each label says.
If you end up paying cash
The cheapest verified GLP-1 routes — what you pay per month once titrated, not an introductory rate:
- Strut Health$129/moverified 2026-09-22compounded, not FDA approvedFDA warning letter
- Noom Med$249/moverified 2026-09-22compounded, not FDA approved
- Found$289/moverified 2026-09-22compounded, not FDA approved
Cheaper still, and a different class: Qsymia (phentermine/topiramate) at $75/mo — about 9.8% mean weight loss in its trial, against roughly 15 to 21% for the GLP-1s above. It is a real option and it is not a substitute.
The manufacturer programs cut the first fills further, and each one's catch is printed with it. Write the appeal first if you were refused — it costs nothing and the criteria above are what it has to answer.
Other states with criteria of their own
Source: Texas Prior Authorization Program Clinical Criteria — Wegovy , effective 2026-07-30. Read on 2026-09-13. Fee-for-service rules; a managed-care plan in Texas can publish its own formulary and step edits. This is a record of what the payer publishes, not medical or legal advice.