CareSource does not cover Zepbound in Ohio on any of its plans. Tirzepatide for weight loss 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 states that GLP-1 coverage is unavailable for “non-FDA approved uses (such as prediabetes or weight loss).”3Ohio SPBM. Ohio Single Pharmacy Benefit Manager Home
Why CareSource Medicaid and MyCare Plans Exclude It
Medicaid coverage of GLP-1 drugs for obesity is optional under federal law. States must cover these drugs for conditions like type 2 diabetes, but they can exclude weight-loss use. Only 13 state Medicaid programs cover GLP-1s for obesity as of 2026, and Ohio is not one of them.4Stateline. More States Consider Dropping GLP-1 Weight Loss Drugs From Medicaid
Because CareSource administers Ohio Medicaid benefits, its pharmacy coverage follows the state’s Unified Preferred Drug List, managed by Gainwell Technologies. Effective November 7, 2025, claims for preferred GLP-1 receptor agonists require a documented diagnosis of type 2 diabetes.3Ohio SPBM. Ohio Single Pharmacy Benefit Manager Home Tirzepatide is available under its diabetes brand name, Mounjaro, with prior authorization, but only for patients with type 2 diabetes, and the state generally requires documentation that the patient had an inadequate response to Ozempic or cannot take it.5Ohio SPBM. Ohio Medicaid SPBM Prior Authorization Announcements
CareSource Marketplace Plans in Ohio
The 2026 CareSource Marketplace (ACA exchange) formulary does not list Zepbound or tirzepatide either.1CareSource. 2026 CareSource Marketplace Plan Formulary The formulary notes it is “not a complete list of drugs that may be covered,” and CareSource’s Pharmacy and Therapeutics Committee updates it quarterly. To confirm the status for your specific plan, use the “Price A Medication” tool on CareSource.com or check your Evidence of Coverage.6CareSource. CareSource Ohio Marketplace Preferred Drug List
The April 2026 Wegovy Change Does Not Apply
Ohio Medicaid did expand GLP-1 coverage in a narrow way in April 2026, but the expansion covers Wegovy (semaglutide) only. The Ohio Department of Medicaid created a new category called “Metabolic Modifiers: GLP-1 Receptor Agonists for Non-Obesity Indications” and designated Wegovy as preferred, with prior authorization, for cardiovascular risk reduction in certain adults with a BMI of at least 27 and for non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced liver fibrosis.7Ohio Department of Medicaid. 30-Day Change Notice, Effective April 1, 2026 Zepbound and tirzepatide were not added to this category, and the criteria explicitly prohibit combining Wegovy with any other GLP-1 or GLP-1/GIP agent.8Ohio Department of Medicaid. Pharmacy and Therapeutics Committee Meeting Minutes, January 7, 2026
What You Can Do if You Still Need Zepbound
None of the paths below guarantees coverage, but each is worth knowing about.
- Ask for a formulary exception. CareSource Medicaid members can request an exception for a drug that is not on the preferred list. Your prescriber submits a supporting statement; for MyCare Ohio plans it can be faxed to 1-877-328-9660. Standard decisions come within 72 hours, expedited within 24. Marketplace members can also submit exception requests through the process on CareSource’s preferred drug list page. An exception based on weight loss is unlikely to succeed given the state’s explicit exclusion of that indication.2CareSource. CareSource MyCare Ohio HMO D-SNP List of Covered Drugs9CareSource. CareSource Preferred Drug List
- Consider another FDA-approved indication. Zepbound is FDA-approved for moderate to severe obstructive sleep apnea in adults with obesity. Medicaid coverage for FDA-approved indications is generally required, so a prescriber could pursue prior authorization on that basis for a patient who qualifies.10KFF. Medicaid Coverage of and Spending on GLP-1s
- Look at Lilly’s self-pay program (commercial plans only). If you have a CareSource Marketplace commercial plan that doesn’t cover Zepbound, Eli Lilly’s self-pay savings card brings costs as low as $499 per month for the single-dose pen, or $299 to $449 per month for the KwikPen. These programs are not available to anyone enrolled in Medicaid, Medicare, or other government-funded insurance, which rules out CareSource Medicaid and MyCare members.11Eli Lilly. Zepbound Savings
- Call for a direct answer on your plan. Ohio Medicaid members can reach Gainwell Technologies Member Services at 1-833-491-0344 or a CareSource pharmacist at 1-833-230-2073. MyCare Ohio members can call 1-855-475-3163.12CareSource. CareSource Ohio Medicaid Preferred Drug List2CareSource. CareSource MyCare Ohio HMO D-SNP List of Covered Drugs