Texas Medicaid does cover Ozempic, but only when it’s prescribed for type 2 diabetes or to reduce cardiovascular risk in patients with heart disease, and only after prior authorization is approved. It will not pay for Ozempic prescribed for weight loss. That line is drawn by state rule, not by individual plan choice, so the answer is the same whether you’re enrolled with Superior HealthPlan, Molina, UnitedHealthcare Community Plan, or any other Texas Medicaid managed care organization.1Texas Vendor Drug Program. Texas Medicaid Preferred Drug List
What Ozempic Is Covered For
The Texas Medicaid Vendor Drug Program lists Ozempic (semaglutide) on its formulary for two FDA-approved uses: treating type 2 diabetes mellitus, and reducing major adverse cardiovascular events in patients with established heart disease or high cardiovascular risk.2Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists The state considers it an appropriate first-line option for patients with type 2 diabetes who also have, or are at high risk of developing, atherosclerotic cardiovascular disease or chronic kidney disease.
Every Texas Medicaid enrollee uses the same statewide formulary, but each managed care organization runs its own pharmacy prior authorization paperwork. Turnaround times and forms differ from plan to plan; the underlying clinical rules do not.
What You Need for Prior Authorization
Ozempic isn’t dispensed at the pharmacy counter on your prescription alone. Your prescriber has to submit a prior authorization request that meets the state’s Drug Utilization Review Board criteria. Using Superior HealthPlan’s clinical edit as a representative example, approval generally requires:3Superior HealthPlan. GLP-1 Clinical Edit Criteria
- You are at least 18 years old.
- You have a diagnosis of type 2 diabetes recorded within the past year.
- You have tried an oral antidiabetic medication such as metformin for at least 14 days in the past year, or you already have a documented history of using the GLP-1 medication being requested during that period.
- You do not have a recent history of end-stage renal disease, advanced chronic kidney disease (stage IV or V), pancreatitis, or gastroparesis.
Statewide contraindications apply on top of the plan-level criteria. Requests are denied if you have a personal or family history of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2, pregnancy, or acute pancreatitis.2Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists
Dosing Limits That Trigger Review
Approved dosing follows the standard titration: 0.25 mg once weekly for four weeks, then 0.5 mg. If blood sugar control is still inadequate after another four weeks, the dose can go to 1 mg, and eventually to a maximum of 2 mg weekly. Prescriptions above that ceiling are flagged for additional review.
Why Weight Loss Isn’t Covered
Texas Medicaid will not pay for Ozempic, Wegovy, or any other GLP-1 medication if the sole purpose is weight loss or obesity management. The authority for that exclusion is Texas Administrative Code Rule §354.1923, which lets the Health and Human Services Commission deny coverage for “obesity control drugs” as one of 26 excluded drug categories.4Cornell Law Institute. 1 Tex. Admin. Code § 354.1923 The rule dates to 1987 and was last amended in 2016.
The Vendor Drug Program’s October 2024 criteria confirm the point, noting that products like Wegovy and Saxenda are not covered for obesity indications under this rule.2Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists Texas is not an outlier. As of January 2026, only 13 state Medicaid programs nationwide covered GLP-1 medications for obesity, and that number has been shrinking as states drop the benefit under cost pressure.5KFF. Medicaid Coverage of and Spending on GLP-1s
Other GLP-1 Drugs Your Doctor Might Mention
If your prescriber is weighing alternatives, a few narrow pathways exist for other GLP-1s. Wegovy, which is a higher-dose semaglutide, became covered under the pharmacy benefit as of December 27, 2024 for reducing major adverse cardiovascular events in adults with established cardiovascular disease, subject to clinical prior authorization.6Texas Children’s Health Plan. Wegovy Coverage and Implementation of Clinical Prior Authorization for Medicaid Effective November 24, 2025, Texas Medicaid added a second Wegovy indication for metabolic dysfunction-associated steatohepatitis (MASH), a serious form of fatty liver disease.7TMHP. Wegovy Clinical Prior Authorization: New MASH Indication Neither pathway is a workaround for weight loss coverage; both require documented cardiovascular disease or biopsy-confirmed liver disease, and concurrent use with another GLP-1 disqualifies the request.8Texas Prior Authorization Program. Wegovy Clinical Prior Authorization Criteria
Zepbound (tirzepatide) is covered only for moderate to severe obstructive sleep apnea combined with obesity, confirmed by a sleep study showing an apnea-hypopnea index of 15 or more events per hour. Initial approval lasts six months, and renewal requires at least 5% weight loss from baseline.9Texas HHS. Zepbound Clinical Prior Authorization Criteria Mounjaro, which contains the same active ingredient marketed for type 2 diabetes, sits in the same GLP-1 framework as Ozempic and requires prior authorization.
If You’re Denied or Uninsured
When prior authorization is approved for an eligible indication, out-of-pocket costs on Medicaid should be minimal. Manufacturer savings cards do not apply to Medicaid enrollees.10Ozempic. Save on Ozempic
If you’re uninsured, or you have Medicaid but were denied coverage, Novo Nordisk runs the NovoCare Patient Assistance Program. It provides Ozempic at no cost to qualifying patients whose household income is at or below 200% of the federal poverty level. If you’re Medicaid-eligible, you must submit a Medicaid denial letter before you can enroll. Applications go in online with proof of income and a government-issued ID, and enrollment lasts 12 months before it needs to be renewed.11NovoCare. Patient Assistance Program
For paying cash without assistance, Novo Nordisk’s self-pay pricing runs $199 per month for the first two months for new patients on the 0.25 mg or 0.5 mg pen, then $349 per month for existing patients on lower doses, and $499 for the 2 mg pen.10Ozempic. Save on Ozempic