Carrier
Ambetter Health (Centene)
Treats Wegovy and Zepbound for weight management as a benefit exclusion, but still reviews Wegovy for heart risk and Zepbound for sleep apnea.
Ambetter is Centene's Marketplace plan, and Centene writes one clinical policy per drug for its health plans. Its Wegovy and Zepbound policies settle the benefit question first: using either drug for weight management is a benefit exclusion, and it won't be authorized.
That exclusion is narrower than it sounds. The same Wegovy policy still sets criteria for lowering heart risk after a heart attack or stroke, and the Zepbound policy sets criteria for moderate to severe obstructive sleep apnea.
The member contract says the same thing from your side. Ambetter's 2026 Georgia contract doesn't pay for weight loss drugs unless they're on the formulary, and Wegovy, Zepbound, Saxenda and Foundayo aren't on Georgia's 2026 list.
What does Centene ask for Wegovy for heart risk?
You need a history of heart attack, stroke or symptomatic peripheral arterial disease, a BMI of 27 or more, and at least 6 months in a physician-directed weight loss program that continues while you take Wegovy.
The first approval runs 6 months. To renew the first time, you need to have lost at least 5% of your starting weight.
What about Zepbound for sleep apnea?
Centene reviews Zepbound for moderate to severe sleep apnea confirmed by a sleep study, when symptoms continue despite using PAP therapy or you can't use PAP. The same 6-month weight program requirement applies.
If your prescription is for the single-dose Zepbound pen, the policy sends you to the Zepbound KwikPen instead.
Every claim above, with the document behind it
These are the policies we opened and the month we opened them. Each one carries its own policy number and effective date on its face, and those are printed here as the document shows them.
Centene's Wegovy policy, written for the "HIM/ICHRA, Medicaid" lines of business, says: "Use of Wegovy for the treatment of weight management is a benefit exclusion and will not be authorized."
Centene Corporation, Clinical Policy: Semaglutide (Wegovy), CP.PMN.295, effective September 2026 · source
For cardiovascular event prevention the member needs established disease ("History of myocardial infarction", "History of stroke" or "Symptomatic peripheral arterial disease (PAD)"), "Body mass index (BMI) ≥ 27 kg/m2", and to have "Been actively enrolled in a physician-directed weight loss program for at least 6 months".
Centene Corporation, Clinical Policy: Semaglutide (Wegovy), CP.PMN.295, effective September 2026 · source
The heart-risk approval is "Approval duration: 6 months", and the first renewal requires that "member has lost ≥ 5% of baseline body weight".
Centene Corporation, Clinical Policy: Semaglutide (Wegovy), CP.PMN.295, effective September 2026 · source
"Use of Zepbound for the treatment of weight management is a benefit exclusion and will not be authorized."
Centene Corporation, Clinical Policy: Tirzepatide (Zepbound), CP.PMN.298 (posted by Ambetter from Superior HealthPlan), effective August 2026 · source
For sleep apnea the policy requires a "Diagnosis of moderate to severe OSA confirmed by recent polysomnography or home sleep apnea test" and either "Member has continued symptoms of OSA despite adherence to positive airway pressure (PAP) therapy" or "Member is not a candidate for PAP therapy", plus a member who has "Been actively enrolled in a physician-directed weight loss program for at least 6 months". It adds: "If request is for Zepbound Pre-filled Single-Use Pen formulation, member must use Zepbound KwikPen formulation".
Centene Corporation, Clinical Policy: Tirzepatide (Zepbound), CP.PMN.298 (posted by Ambetter from Superior HealthPlan), effective August 2026 · source
Under prescription drug exclusions, no benefits are paid "For weight loss prescription drugs unless otherwise listed on the formulary."
Ambetter from Peach State Health Plan (Georgia), 2026 Evidence of Coverage, 70893GA001-2026, effective January 2026 · source
Wegovy, Zepbound, Saxenda and Foundayo are not listed on Ambetter's Georgia formulary marked "EFFECTIVE JANUARY 1, 2026".
Ambetter from Peach State Health Plan (Georgia), 2026 Formulary, effective January 2026 · source
What these documents cannot tell you
Everything above is what Ambetter Health (Centene) publishes. None of it establishes what your own plan does, and the gap between those two things is wider than a carrier policy makes it look.
- These are Centene's company-wide policies. Your state's Ambetter contract and formulary are the documents that bind your plan, and the contract and drug list quoted here are Georgia's.
- Centene's Medicaid plans use the same Wegovy and Zepbound policies, but in Medicaid your state's program decides whether weight-loss drugs are a covered benefit at all. Coverage depends on the state program, and a Medicaid denial can go to a state fair hearing.
- The Centene policies quoted here cover Wegovy and Zepbound. For Saxenda and Foundayo, the Georgia drug list is the only document quoted.
- A heart-risk or sleep apnea approval still depends on the documents your prescriber sends. The policy doesn't tell you whether your records meet it.
- None of this is legal or medical advice. Your plan documents and your notice govern your case.
Where this comes from
- Centene Corporation, Clinical Policy: Semaglutide (Wegovy), CP.PMN.295, effective September 2026 — Open the document
- Centene Corporation, Clinical Policy: Tirzepatide (Zepbound), CP.PMN.298 (posted by Ambetter from Superior HealthPlan), effective August 2026 — Open the document
- Ambetter from Peach State Health Plan (Georgia), 2026 Evidence of Coverage, 70893GA001-2026, effective January 2026 — Open the document
- Ambetter from Peach State Health Plan (Georgia), 2026 Formulary, effective January 2026 — Open the document
Where to go next
- When a weight-loss exclusion doesn't block every use
- When insurance covers Zepbound for sleep apnea
- Georgia Medicaid and state employee coverage
- How Medicaid treats GLP-1s, state by state
- How to ask for a Medicaid fair hearing
- How to appeal a commercial or Marketplace plan denial
- Every carrier we have read
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page describes what Ambetter Health (Centene) publishes. It is not affiliated with Centene Corporation, and your own plan documents and your own notice govern your case. Policies carry effective dates and change — read the sources before you act.