State coverage
Medicaid, for obesity: Covers with conditions. The conditions and the appeal deadline are in the summary below.
Texas was missing from this site for two rounds because its own pharmacy sites answered us with 403 Forbidden. That was never Texas declining to publish. The state's servers screen for a full browser fingerprint rather than a user-agent string, and once the request carried one the same pages opened normally. We are writing that down because a blocked page and an absent page look identical from the outside, and treating the first as the second is how a site ends up printing something false about a state.
What Texas actually does is more specific than either of the labels usually applied to it. It covers Wegovy and it covers Zepbound. It also refuses both for obesity on its own. Wegovy runs through cardiovascular disease at 45 or over, or through non-cirrhotic liver disease with confirmed stage F2 to F3 fibrosis. Zepbound runs through moderate to severe sleep apnea with a measured apnea-hypopnea index of at least 15. Obesity appears in both as a box that also has to be ticked, never as the reason.
Two of these prior authorizations are unusual in a way worth knowing if you are in a managed care plan. Texas requires its plans to work a short list of clinical prior authorizations statewide, and Wegovy and Zepbound are two of the four on it. The state also says plainly that plans have to use its formulary, so this is one of the states where the answer above is the answer wherever you are enrolled.
Two limits on what follows. The criteria documents are published by the state's prior-authorization vendor and are linked from the Vendor Drug Program's own criteria page rather than sitting on a Texas government domain; we are citing them as what the state's contractor publishes as the state's criteria. And Texas's drug-level status lives only in the formulary search tool — we read the September 2026 provider manual chapters on outpatient drugs, prior authorization, managed care and appeals, and not one of them mentions any GLP-1 by name, so anyone checking the manual alone would find nothing and could mistake that for an absence.
Wegovy's Texas criteria never open on obesity. The document walks a numbered logic: it first asks whether you are 45 or over, then whether you have a diagnosis of cardiovascular disease, and only then asks about "a diagnosis of obesity or overweight in past medical and/or pharmacy claims history." The other way in is liver disease — non-cirrhotic MASH with "moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis)," confirmed by biopsy or by a named non-invasive test within the last 180 days. An approval runs 365 days.
Texas Prior Authorization Program Clinical Criteria, Wegovy (Semaglutide), effective May 2026 · source · read August 2026
Zepbound goes through sleep apnea. The criteria ask whether you are 18 or over, then whether you have "a diagnosis of moderate to severe obstructive sleep apnea (OSA)," then whether you have "an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT)," and then about a diagnosis of obesity. An initial approval runs 180 days. To renew it you have to show results: "Has the client lost or maintained a loss of at least 5% from their baseline weight?"
Texas Prior Authorization Program Clinical Criteria, Zepbound (Tirzepatide), effective May 2026 · source · read August 2026
Being in a Texas managed care plan does not change the drug list. The Vendor Drug Program states that "HHSC requires managed care organizations to adhere to the Medicaid and CHIP formularies."
Texas Health and Human Services, Vendor Drug Program · source · read August 2026
It also does not change these two criteria. Texas requires its plans to run a specific short list of clinical prior authorizations, and the GLP-1 weight drugs are on it: "Clinical prior authorizations required by MCOs to perform for clients enrolled in Medicaid include the following: Hormonal Therapy Agents (PDF) Promethazine Agents (PDF) Wegovy (PDF) Zepbound (PDF)." Four are required statewide and two of them are these.
Texas Health and Human Services, Vendor Drug Program · source · read August 2026
Texas gives you 90 calendar days, and it measures from whichever of two dates is later. Its hearings handbook says: "The appellant has a right to file an appeal within 90 calendar days from the effective date of the action or from the notice of adverse action date, whichever is later." The same handbook lists "the denial of a prior authorization request" among the things you can appeal, and adds a note worth carrying: agency staff "may not prevent a client from filing an appeal because staff believe that the item, service or benefit is not subject to appeal," because the hearings officer decides that.
Texas Health and Human Services Commission, Fair and Fraud Hearings Handbook §1420, effective May 2025 · source · read August 2026
We read four chapters of the Texas Medicaid Provider Procedures Manual dated September 2026 — outpatient drug services, prior authorization, managed care, and appeals — and searched all four for every GLP-1 brand and molecule in scope, and for the terms GLP-1, weight loss and obesity. Not one of them appears anywhere in those chapters, while prior authorization appears hundreds of times, so the search was working. In Texas the manual is not where drug-level status lives; the formulary search and the criteria documents are.
Texas Medicaid and Healthcare Partnership, Texas Medicaid Provider Procedures Manual, effective September 2026 · source · read August 2026
Medicaid is only one of the routes. If you have a commercial or employer plan, the rules are different and are on the employer plans page; Medicare has a federal rule of its own, on the Part D page.
If the appeal fails, or you cannot wait
Cash-pay telehealth is the fallback, not the bargain: you pay the whole cost yourself, and a covered prescription is almost always cheaper than any of these. Use this route when coverage has actually been exhausted, or when you need to start while an appeal runs.
These companies pay us a commission if you start care through the links below. That is how this site is funded, and it does not change what is written above. How we pay for this.
Prices in those notes were read from each company's own site in August 2026 and change often. Check the current number before you buy.
Every state we have verified is in the coverage matrix. Appeal routes and deadlines are on the procedures page.