Carrier
Molina Healthcare
Excludes Wegovy and Zepbound for obesity; most Marketplace plans exclude them for every use, while Illinois Medicaid keeps heart and sleep apnea paths.
Molina writes separate drug criteria for its Medicaid plans and its Marketplace plans. Both sets start from the same point: Wegovy and Zepbound are excluded for overweight and obesity, citing the federal Medicaid rule that lets a state leave weight-loss drugs out.
On the Marketplace the exclusion reaches further. In states where weight-loss drugs are a benefit exclusion, Molina treats Wegovy and Zepbound as excluded for every use, including heart-risk reduction and sleep apnea. California and New Mexico are the exceptions the criteria name.
On Medicaid, Molina tells its reviewers to check your state's benefits first. Its Illinois criteria keep a path for Wegovy after a heart attack or stroke and for Zepbound for sleep apnea.
What's left under Molina Medicaid in Illinois?
Wegovy for heart-risk reduction needs established cardiovascular disease, no diabetes diagnosis, and a cardiologist prescribing or consulting. The first approval runs 6 months, then 12.
Zepbound for sleep apnea needs a pulmonologist or sleep specialist and a prior attempt at weight loss through diet. It's also approved for 6 months first, then 12.
Can a formulary exception get you around the Marketplace exclusion?
No. Molina's Illinois Marketplace formulary says benefit exclusions are not covered at all and can't be approved by formulary exception. Wegovy, Zepbound, Saxenda and Foundayo aren't on that list.
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.
"In states where weight loss drugs are a benefit exclusion, Zepbound (tirzepatide) is considered a benefit exclusion for all indications, including but not limited to weight reduction and chronic weight management, weight reduction to treat moderate to severe obstructive sleep apnea".
Molina Healthcare, Drug and Biologic Coverage Criteria: Zepbound (tirzepatide) NC, C29112-A (Marketplace), effective August 2026 · source
Wegovy "injection and tablets are considered a benefit exclusion for all indications, including but not limited to weight reduction and chronic weight management, weight reduction to lower risk for repeat cardiovascular event in individuals with history of prior heart attack or stroke" in those states, and "Weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage."
Molina Healthcare, Drug and Biologic Coverage Criteria: Wegovy (semaglutide) NC, C27682-A (Marketplace), effective May 2026 · source
"For California Marketplace and New Mexico Marketplace, please see Appendix." The appendix quotes New Mexico: "Prescription drugs medically necessary for the treatment of obesity and morbid obesity are also covered."
Molina Healthcare, Drug and Biologic Coverage Criteria: Zepbound (tirzepatide) NC, C29112-A (Marketplace), effective August 2026 · source
"Non-covered drugs or other products such as benefit exclusions are not covered at all. They cannot be approved for coverage by formulary exception." Wegovy, Zepbound, Saxenda and Foundayo are not listed on this formulary.
Molina Healthcare of Illinois, 2026 Marketplace Formulary (List of Covered Drugs), effective July 2026 · source
"MOLINA REVIEWER NOTE: PLEASE FIRST REFER TO STATE AND LINE OF BUSINESS EXPLANATION OF BENEFITS TO DETERMINE IF WEIGHT LOSS IS A COVERED BENEFIT." Then: "Wegovy (semaglutide) is excluded from coverage for overweight/obesity per Social Security 1927 (d)(3)(A)." The quoted statute lists "Agents when used for anorexia, weight loss, or weight gain."
Molina Healthcare of Illinois, Drug and Biologic Coverage Criteria: Wegovy (semaglutide) MNR, C27635-A (Medicaid), effective May 2026 · source
For cardiovascular risk reduction: "Documented diagnosis of cardiovascular disease as evidenced by history of myocardial infarction, history of stroke (ischemic or hemorrhagic), or symptomatic peripheral arterial disease", "Documentation member does NOT have a diagnosis of Type 1 or Type 2 diabetes", and "Prescribed by or in consultation with a board-certified cardiologist". Approval: "Cardiovascular Risk Reduction: Initial authorization: 6 months, Continuation of Therapy: 12 months".
Molina Healthcare of Illinois, Drug and Biologic Coverage Criteria: Wegovy (semaglutide) MNR, C27635-A (Medicaid), effective May 2026 · source
For obstructive sleep apnea: "Member has previously attempted weight loss through dietary changes" and "Prescribed by or in consultation with a board-certified pulmonologist or sleep medicine specialist", with "Initial authorization: 6 months, Continuation of Therapy: 12 months".
Molina Healthcare of Illinois, Drug and Biologic Coverage Criteria: Zepbound (tirzepatide) MNR, C29111-A (Medicaid), effective December 2025 · source
What these documents cannot tell you
Everything above is what Molina Healthcare 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.
- Medicaid coverage depends on your state's program. Molina's reviewers check the state's benefits first, and the Illinois criteria quoted here don't tell you what Molina does in another state.
- If your Molina Medicaid plan denies a GLP-1, you can appeal to the plan and then ask your state for a fair hearing.
- The Illinois Medicaid Zepbound criteria are an older version due for review, so a newer one may replace them.
- California and New Mexico Marketplace members fall under separate weight-management criteria that weren't read here.
- None of this is legal or medical advice. Your plan documents and your notice govern your case.
Where this comes from
- Molina Healthcare, Drug and Biologic Coverage Criteria: Zepbound (tirzepatide) NC, C29112-A (Marketplace), effective August 2026 — Open the document
- Molina Healthcare, Drug and Biologic Coverage Criteria: Wegovy (semaglutide) NC, C27682-A (Marketplace), effective May 2026 — Open the document
- Molina Healthcare of Illinois, 2026 Marketplace Formulary (List of Covered Drugs), effective July 2026 — Open the document
- Molina Healthcare of Illinois, Drug and Biologic Coverage Criteria: Wegovy (semaglutide) MNR, C27635-A (Medicaid), effective May 2026 — Open the document
- Molina Healthcare of Illinois, Drug and Biologic Coverage Criteria: Zepbound (tirzepatide) MNR, C29111-A (Medicaid), effective December 2025 — Open the document
Where to go next
- How Medicaid treats GLP-1s, state by state
- How to ask for a Medicaid fair hearing
- Illinois Medicaid and state employee coverage
- When insurance covers Zepbound for sleep apnea
- When a weight-loss exclusion doesn't block every use
- 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 Molina Healthcare publishes. It is not affiliated with Molina Healthcare, Inc., and your own plan documents and your own notice govern your case. Policies carry effective dates and change — read the sources before you act.