CareSource does not cover Zepbound in Ohio. The drug is absent from the CareSource Ohio Marketplace formulary, the CareSource MyCare Ohio dual-eligible formulary, and the Ohio Medicaid Unified Preferred Drug List that governs pharmacy benefits for every Medicaid managed care plan in the state.1CareSource. 2026 CareSource Marketplace Plan Formulary2CareSource. CareSource MyCare Ohio HMO D-SNP List of Covered Drugs Ohio’s pharmacy benefit manager has stated that GLP-1 receptor agonists are not covered for “non-FDA approved uses (such as prediabetes or weight loss).”3Ohio SPBM. Ohio Single Pharmacy Benefit Manager Home
Why CareSource Medicaid Plans Exclude Zepbound
Federal law lets state Medicaid programs decide whether to cover GLP-1 drugs prescribed for obesity. Coverage is required for conditions like type 2 diabetes and, more recently, obstructive sleep apnea in adults with obesity, but states may exclude these drugs when they are prescribed purely for weight loss.4KFF. Medicaid Coverage of and Spending on GLP-1s Ohio has taken the exclusion. As of 2026, only 13 state Medicaid programs cover GLP-1s for obesity, and Ohio is not one of them.5Stateline. More States Consider Dropping GLP-1 Weight Loss Drugs From Medicaid
CareSource administers Ohio Medicaid benefits, so its pharmacy coverage follows the state’s Unified Preferred Drug List, managed by Gainwell Technologies as the state’s Single Pharmacy Benefit Manager. Effective November 7, 2025, claims for preferred GLP-1 receptor agonists require a documented diagnosis of type 2 diabetes, and weight loss is explicitly a non-covered use.3Ohio SPBM. Ohio Single Pharmacy Benefit Manager Home Tirzepatide, the active ingredient in Zepbound, is available under its diabetes brand name Mounjaro with prior authorization, but that pathway is limited to type 2 diabetes and generally requires documentation that the patient had an inadequate response to Ozempic or cannot use it.6Ohio SPBM. Ohio Medicaid SPBM Prior Authorization Announcements
CareSource Marketplace Plans in Ohio
CareSource’s 2026 Ohio Marketplace (ACA exchange) formulary also does not list Zepbound or tirzepatide.1CareSource. 2026 CareSource Marketplace Plan Formulary The formulary is updated quarterly by CareSource’s Pharmacy and Therapeutics Committee and notes that it is “not a complete list of drugs that may be covered.” To confirm coverage for a specific plan year and metal tier, use the Price A Medication tool on CareSource.com or check your Evidence of Coverage.7CareSource. CareSource Ohio Marketplace Preferred Drug List
The April 2026 Wegovy Expansion Does Not Include Zepbound
Ohio Medicaid did add a narrow slice of GLP-1 coverage in April 2026, but only for Wegovy (semaglutide). The Ohio Department of Medicaid created a category called “Metabolic Modifiers: GLP-1 Receptor Agonists for Non-Obesity Indications” and designated Wegovy as preferred, with clinical prior authorization, for two uses.8Ohio Department of Medicaid. 30-Day Change Notice, Effective April 1, 2026
The first is cardiovascular risk reduction in adults 18 and older with a BMI of at least 27 who do not have diabetes and who have a history of heart attack, stroke, or symptomatic peripheral artery disease. The second is treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced liver fibrosis. Both require extensive documentation, including proof that the patient is already receiving standard-of-care treatment for related conditions.9Ohio Department of Medicaid. Pharmacy and Therapeutics Committee Meeting Minutes, January 7, 2026
Zepbound and tirzepatide were not added to this new category, and the criteria explicitly prohibit combining Wegovy with any other GLP-1 or GLP-1/GIP agent.8Ohio Department of Medicaid. 30-Day Change Notice, Effective April 1, 2026
Options if You Still Need Zepbound
None of the routes below guarantee coverage, but each is worth knowing about.
- Request a formulary exception. CareSource Medicaid members can ask for an exception when a drug is not on the preferred list. Your prescriber submits a supporting statement, which for MyCare Ohio plans can be faxed to 1-877-328-9660. Decisions are generally issued within 72 hours, or 24 hours for expedited requests. Marketplace members can submit exception requests through the process outlined on CareSource’s preferred drug list page. An exception for weight loss is unlikely to be approved given Ohio Medicaid’s explicit exclusion of that indication.2CareSource. CareSource MyCare Ohio HMO D-SNP List of Covered Drugs10CareSource. CareSource Preferred Drug List
- Ask your prescriber about other FDA-approved indications. Zepbound is FDA-approved for moderate to severe obstructive sleep apnea in adults with obesity. Medicaid coverage for FDA-approved indications is generally required, and a prior authorization on that basis is a possibility if the patient qualifies.4KFF. Medicaid Coverage of and Spending on GLP-1s
- Look at Eli Lilly’s self-pay program if you have a commercial plan. Patients on a CareSource Marketplace commercial plan whose plan does not cover Zepbound may qualify for Lilly’s savings card, which brings the cost as low as $499 per month for the single-dose pen or $299 to $449 per month for the KwikPen. These savings programs are not available to anyone enrolled in Medicaid, Medicare, or other government-funded insurance.11Eli Lilly. Zepbound Savings
- Call to confirm before you fill. For Ohio Medicaid questions on specific prescriptions, Gainwell Technologies Member Services is at 1-833-491-0344, and a CareSource pharmacist can be reached at 1-833-230-2073. MyCare Ohio members can reach Member Services at 1-855-475-3163.12CareSource. CareSource Ohio Medicaid Preferred Drug List2CareSource. CareSource MyCare Ohio HMO D-SNP List of Covered Drugs