Texas Medicaid does cover Mounjaro, but only when it is prescribed to treat type 2 diabetes. A prescription written for weight loss will not be approved. Even for diabetes, Mounjaro requires prior authorization, and the prescriber has to document a confirmed diagnosis along with prior treatment attempts before the pharmacy can fill it.
Mounjaro has been on the Texas Vendor Drug Program formulary for Medicaid, CHIP, and CSHCN since February 2023, classified under incretin mimetics and approved for type 2 diabetes mellitus.1Texas Vendor Drug Program. Formulary Drug Search – Mounjaro Weight-loss use is excluded under Texas Administrative Code §354.1923, which authorizes the Health and Human Services Commission to deny coverage for obesity-control drugs.2Cornell Law Institute. 1 Tex. Admin. Code § 354.1923 – Review and Evaluation Orlistat has historically been the only weight-loss drug Texas Medicaid pays for.3Becker’s Payer Issues. States Considering Adding Weight Loss Drug Coverage Under Medicaid
What Prior Authorization Requires
Mounjaro is flagged for both Preferred Drug List prior authorization and fee-for-service clinical prior authorization under the GLP-1 Receptor Agonists clinical criteria that have been in effect since November 2022.1Texas Vendor Drug Program. Formulary Drug Search – Mounjaro To get a request approved, the prescriber generally needs to document the following:
- A confirmed type 2 diabetes diagnosis.
- Evidence that other treatments, typically lifestyle changes and metformin, have been tried and were insufficient.
- The patient’s body mass index.
- That the patient is not already on another GLP-1 agonist. Overlapping prescriptions in this drug class are flagged for review as duplicative therapy.4Texas Health and Human Services Commission. DURB Agenda Item 10c
Dosing is expected to follow the label: start at 2.5 mg once weekly and increase in 2.5 mg increments every four weeks as needed, up to a maximum of 15 mg weekly. Prescriptions that exceed these guidelines are subject to review.4Texas Health and Human Services Commission. DURB Agenda Item 10c
If You Have a Managed Care Plan
Most Texas Medicaid members get their coverage through a managed care organization rather than traditional fee-for-service Medicaid. These plans generally follow the state Vendor Drug Program formulary and criteria, but each one can add its own paperwork on top.
Molina Healthcare of Texas, for example, requires prior authorization for Mounjaro with supporting clinical notes, lab work, and medication history.5Molina Healthcare. Texas Medicaid CHIP Prior Authorization Criteria Guide UnitedHealthcare Community Plan of Texas routes providers to the state Vendor Drug Program’s clinical criteria along with its own Pharmacy Clinical Prior Authorization Assistance Chart for plan-specific requirements.6UnitedHealthcare. TX Community Plan Clinical PA Criteria If you aren’t sure how your plan handles the request, call the number on your member card or ask your prescriber’s office to start the authorization on your behalf.
If Your Prescription Is for Weight Loss
Tirzepatide is sold under two brand names: Mounjaro for type 2 diabetes, and Zepbound for chronic weight management. The FDA approved Zepbound in November 2023 for adults with obesity or overweight plus at least one weight-related condition.7U.S. Food and Drug Administration. FDA Approves New Medication for Chronic Weight Management Because Texas Medicaid covers tirzepatide only for diabetes, a Mounjaro prescription written to help a patient lose weight generally will not be approved, and a Zepbound prescription for weight loss falls under the obesity-drug exclusion.
There is one narrow exception. In April 2025, Texas opened a prior authorization pathway for Zepbound in adults who have moderate-to-severe obstructive sleep apnea along with an obesity diagnosis. The request must include documented sleep study results and a reduced-calorie diet and exercise plan, and the patient cannot have a conflicting condition such as gastroparesis. Renewals require the patient to have lost or maintained at least five percent of baseline weight.8Texas Health and Human Services Commission. DURB Agenda Item 10d – Zepbound Clinical Criteria
If Prior Authorization Is Denied
The Texas Prior Authorization Program allows exceptions when a non-preferred drug is clinically necessary. A request can still be approved if the patient has had treatment failure on preferred alternatives, has a documented contraindication or allergic reaction to the preferred drugs, or if the preferred options are likely to cause harm based on the patient’s clinical history.9Texas Prior Authorization Program. PDL Criteria Guide Your prescriber would submit the clinical rationale and supporting records with the exception request.
Why the Lilly Savings Card Won’t Help
Eli Lilly’s Mounjaro Savings Card advertises prescriptions for as low as $25, but it explicitly excludes anyone enrolled in Medicaid, Medicare, TRICARE, VA, or any other government-funded health plan.10Eli Lilly and Company. Mounjaro Savings Resources for HCPs11Eli Lilly and Company. Mounjaro Savings and Coverage Patients attest at enrollment that they are not in a government program and must stop using the card if they later become enrolled. If you have Texas Medicaid, this card is not an option.
Lilly’s charitable patient assistance program, Lilly Cares, does cover Mounjaro for diabetes for uninsured or underinsured patients, which can matter if Medicaid denies the prior authorization and no other coverage picks it up.12FindHonestCare. Zepbound Patient Assistance Lilly Cares does not cover Zepbound. For general questions, Lilly Support Services can be reached at 1-800-545-5979.11Eli Lilly and Company. Mounjaro Savings and Coverage
What Could Change
Two developments could shift Texas policy, though neither has yet. During the 89th Texas Legislative Session, Representative Thompson filed House Bill 2677, which would require Medicaid to cover anti-obesity medications, bariatric surgery, intensive behavioral therapy, and diabetes prevention programs, with medical necessity criteria no more restrictive than FDA-approved indications.13Texas Legislature. H.B. 267714Texas Health and Human Services Commission. TDC Agenda Item 3 – Legislative Recap Observers tracking similar 2025 bills across states have not expected them to gain significant traction.15MultiState. GLP-1 Weight Loss Drugs Coverage Under Medicaid and Other Health Plans
Separately, in November 2025 the Trump administration announced pricing agreements with Eli Lilly and Novo Nordisk setting Medicare and Medicaid prices for GLP-1 drugs including Mounjaro and Zepbound at $245 per month, with every state Medicaid program promised access to “Most-Favored-Nation” pricing.16The White House. Fact Sheet: President Donald J. Trump Announces Major Developments in Bringing Most Favored Nation Pricing to American Patients17KFF. Medicaid Coverage of and Spending on GLP-1s18CNBC. Trump, Eli Lilly, Novo Nordisk Deal on Obesity Drug Prices Lower prices alone would not force Texas to cover obesity treatment. The state would still have to amend TAC §354.1923 to lift the exclusion.