Texas Medicaid does cover Ozempic, but only when it’s prescribed for type 2 diabetes or to reduce cardiovascular risk in patients with heart disease, and only after prior authorization is approved. It does not cover Ozempic when the prescription is for weight loss.
When Texas Medicaid Pays for Ozempic
The Texas Vendor Drug Program lists Ozempic (semaglutide) on the state Medicaid formulary for two FDA-approved uses: treating type 2 diabetes mellitus and reducing major adverse cardiovascular events in patients with established heart disease or high cardiovascular risk.1Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists For patients with type 2 diabetes who also have atherosclerotic cardiovascular disease or chronic kidney disease, or who are at high risk of developing them, Ozempic is considered an appropriate first-line therapy.
Every Texas Medicaid enrollee uses the same statewide formulary, no matter which managed care organization they’re enrolled in. Each MCO (Superior HealthPlan, Molina, UnitedHealthcare Community Plan, and others) runs its own pharmacy prior authorization process, so the forms, contacts, and turnaround times vary between plans.2Texas Vendor Drug Program. Texas Medicaid Preferred Drug List
What You Have to Meet to Get It Approved
Prior authorization is required. The specific checklist differs slightly by MCO, but the clinical criteria follow the state Drug Utilization Review Board guidelines. Superior HealthPlan’s edit criteria give a clear picture of what prescribers are asked to document:3Superior HealthPlan. GLP-1 Clinical Edit Criteria
- You must be at least 18 years old.
- You must have a diagnosis of type 2 diabetes within the past year.
- You must have tried an oral antidiabetic medication such as metformin for at least 14 days in the past year, or already have a history of using the requested GLP-1 within that period.
- Requests are denied if there’s a recent history of end-stage renal disease, stage IV or V chronic kidney disease, pancreatitis, or gastroparesis.
Statewide drug use criteria list absolute contraindications that apply across every MCO: a personal or family history of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2, pregnancy, or acute pancreatitis.1Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists Dosing starts at 0.25 mg weekly for four weeks, moves to 0.5 mg, and can be titrated up to 1 mg and then a maximum of 2 mg weekly. Prescriptions above the recommended maximum get flagged for review.
Why Weight Loss Isn’t Covered
If the prescription is for weight loss, Texas Medicaid will not pay for it, whether the drug is Ozempic, Wegovy, or any other GLP-1 medication. The authority for that exclusion is Texas Administrative Code Rule §354.1923, which lets the Health and Human Services Commission deny coverage for “obesity control drugs.”4Cornell Law Institute. 1 Tex. Admin. Code § 354.1923 The rule was adopted in 1987 and last amended in 2016, and it names obesity drugs as one of 26 excluded drug categories. The October 2024 Vendor Drug Program criteria restate the exclusion plainly, noting that products like Wegovy and Saxenda are not covered for obesity indications.1Texas HHS. Drug Use Criteria: GLP-1 Receptor Agonists
This isn’t unusual. As of January 2026, only 13 state Medicaid programs covered GLP-1 medications for obesity, and the count has been shrinking as states including California, Pennsylvania, and New Hampshire dropped the benefit over cost.5KFF. Medicaid Coverage of and Spending on GLP-1s
Related GLP-1s You Might Be Asking About
Ozempic and Wegovy are both semaglutide, and patients often confuse their coverage status. Wegovy is still excluded for weight loss, but Texas Medicaid has opened two narrow pathways for it. Starting December 27, 2024, Wegovy became covered through the pharmacy benefit to reduce major adverse cardiovascular events in adults with established cardiovascular disease, with clinical prior authorization.6Texas Children’s Health Plan. Wegovy Coverage and Implementation of Clinical Prior Authorization for Medicaid7TMHP. Wegovy Clinical Prior Authorization: New MASH Indication8Texas Prior Authorization Program. Wegovy Clinical Prior Authorization Criteria
Zepbound (tirzepatide) has its own narrow Texas Medicaid pathway: moderate to severe obstructive sleep apnea combined with obesity. The patient must be at least 18, have an apnea-hypopnea index of 15 or more events per hour confirmed by sleep study, carry an obesity diagnosis, and use the medication alongside diet and exercise. Initial approval runs six months, and renewal requires at least 5% weight loss from baseline.9Texas HHS. Zepbound Clinical Prior Authorization Criteria Mounjaro, which is tirzepatide marketed for type 2 diabetes, appears in the state’s GLP-1 tables and falls under the same prior authorization framework as Ozempic for diabetes.
If You’re Denied or Uninsured
When prior authorization is approved for an eligible indication, out-of-pocket costs for Ozempic on Texas Medicaid should be minimal. Manufacturer savings cards and copay discounts are not available to Medicaid enrollees.10Ozempic. Save on Ozempic
If you’re uninsured, or if Medicaid denies your request, Novo Nordisk runs the NovoCare Patient Assistance Program, which provides Ozempic at no cost to qualifying patients with household income at or below 200% of the federal poverty level. Medicaid-eligible applicants must submit a Medicaid denial letter before enrolling. Applications are completed online and require proof of income and a government-issued ID. Enrollment lasts 12 months and must be renewed each year.11NovoCare. Patient Assistance Program
For patients paying out of pocket with no assistance, Novo Nordisk’s reduced self-pay pricing is $199 per month for the first two months for new patients on the 0.25 mg or 0.5 mg pen, $349 per month for existing patients on lower doses, and $499 for the 2 mg pen.10Ozempic. Save on Ozempic