Texas Medicaid does cover Wegovy, but only for two specific medical conditions: reducing cardiovascular risk in adults who already have heart disease, and treating a serious liver condition called MASH. It will not pay for Wegovy prescribed for weight loss alone, and that limit has held even as the drug has become one of the most sought-after medications in the country.
What Is and Is Not Covered
The Texas Health and Human Services Commission added Wegovy to the Medicaid formulary on December 27, 2024, after the Texas Drug Utilization Review Board approved clinical prior authorization criteria.1UnitedHealthcare. TX HHSC Alert – Wegovy Coverage lines up with the FDA’s March 2024 expanded approval of Wegovy “to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.”2U.S. Food and Drug Administration. FDA Approves First Treatment To Reduce Risk of Serious Heart Problems Specifically in Adults With Obesity or Overweight
In November 2025, Texas added a second covered use: non-cirrhotic metabolic dysfunction-associated steatohepatitis, known as MASH, with moderate to advanced liver fibrosis. That pathway took effect November 24, 2025.3Texas Medicaid & Healthcare Partnership. Wegovy Clinical Prior Authorization – New Metabolic Dysfunction-Associated Steatohepatitis Indication
Weight loss is a different story. Texas Administrative Code Rule §354.1923 gives HHSC authority to deny coverage for “amphetamines, when used for weight loss, and obesity control drugs,” and the agency applies that rule to Wegovy and similar drugs like Saxenda when they are prescribed purely for weight management.4Cornell Law Institute. 1 Tex. Admin. Code § 354.19235Texas Health and Human Services. October 2024 DURB Agenda Item 10c Federal law allows this: while state Medicaid programs must cover nearly all FDA-approved outpatient drugs, a longstanding exception permits them to exclude drugs used for weight loss. As of January 2026, only 13 state Medicaid programs cover GLP-1 medications for obesity under fee-for-service, and that number has been shrinking rather than growing.6KFF. Medicaid Coverage of and Spending on GLP-1s
The same drug can therefore be approved for one Medicaid patient and denied for another. The deciding factor is the diagnosis on the prior authorization request.
Who Qualifies
Approval runs through one of two clinical pathways, each with its own baseline requirements.7Texas Prior Authorization Program. Wegovy Clinical Prior Authorization Criteria
Cardiovascular Pathway
- You must be 45 or older.
- You must have a documented diagnosis of cardiovascular disease within the past 730 days.
- You must also have a diagnosis of obesity or overweight within the past 730 days.
MASH Pathway
- You must be 18 or older.
- You must have a diagnosis of non-cirrhotic MASH within the past 730 days.
- You must have moderate to advanced liver fibrosis (stages F2 to F3), confirmed within the past 180 days by liver biopsy or non-invasive testing such as FibroScan, elastography, or MRI.8Texas Health and Human Services. October 2025 DURB Agenda Item 09d – Wegovy MASH Criteria
Rules That Apply to Both Pathways
You have to use Wegovy alongside a reduced-calorie diet and increased physical activity. The dose cannot exceed four pens per 28 days or one tablet per day. You cannot be taking another GLP-1 receptor agonist at the same time, which rules out concurrent use of Ozempic, Mounjaro, or Saxenda. A history of pancreatitis, gastroparesis, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2 within the past 180 days is disqualifying.7Texas Prior Authorization Program. Wegovy Clinical Prior Authorization Criteria
Managed care organizations may add their own requirements. A Wellpoint form for Texas Medicaid, for example, asks whether the patient has had a recent HbA1c test and whether they have tried and failed a 30-day course of at least one preferred agent.9Wellpoint. TX WLP PA Wegovy An approved authorization is good for 365 days.7Texas Prior Authorization Program. Wegovy Clinical Prior Authorization Criteria
How To Get Prior Authorization
You cannot fill a Wegovy prescription at a Texas Medicaid pharmacy without prior authorization in place. Your prescribing provider submits the request, and where it goes depends on your coverage type.
If you are on fee-for-service Medicaid, the request goes to the Texas Medicaid and Healthcare Partnership (TMHP) by mail, fax, or electronic portal. A physician reviewer decides completed requests within three business days.10Texas Medicaid & Healthcare Partnership. Prior Authorization
Most Texas Medicaid recipients are in managed care, and in that case the request goes to your MCO. All MCOs were required to have Wegovy prior authorization processes running by early 2025.1UnitedHealthcare. TX HHSC Alert – Wegovy
What To Do if You Are Denied
A denial is not the end of the road, but the appeal path depends on your coverage.
Fee-for-service enrollees can file a reconsideration using HHSC Form 1322. The form should include supporting documentation such as medical records, lab results, or peer-reviewed literature establishing medical necessity. A healthcare professional reviews it and sends a written decision to the prescribing provider within five business days, with the patient copied by mail. The Texas Prior Authorization Call Center is at 877-728-3927, Monday through Friday, 7 a.m. to 7 p.m. Central.11Texas Health and Human Services. Form 1322 – Medicaid Fee-for-Service Prior Authorization Reconsideration Request
Managed care enrollees have to use the grievance and appeal process built into their MCO. Each plan has its own procedures and deadlines, so start with the member handbook or call the number on your plan card.
Changes That Could Affect Coverage
Two federal developments are worth tracking, though neither has changed Texas’s exclusion of weight-loss coverage.
In November 2025, the Trump administration announced an agreement with Novo Nordisk and Eli Lilly lowering the Medicaid price of Wegovy to $245 per month, well below the roughly $1,350 list price. States have to opt in. Through the TrumpRx platform, direct-to-consumer pricing starts at $350 per month and is set to drop toward $245 over two years.12CNBC. Trump, Eli Lilly, Novo Nordisk Deal on Obesity Drug Prices13The White House. Fact Sheet: President Donald J. Trump Announces Major Developments in Bringing Most Favored Nation Pricing to American Patients
In December 2025, CMS launched the BALANCE model, a voluntary five-year initiative to negotiate lower GLP-1 prices and expand access through Medicaid and Medicare, with states asked to indicate interest by January 8, 2026, and the program expected to begin in May 2026.6KFF. Medicaid Coverage of and Spending on GLP-1s Whether Texas participates in either program has not been announced.
For now, if you want Wegovy through Texas Medicaid, your diagnosis has to match one of the two covered pathways. Weight loss on its own does not qualify, and the state has given no signal it plans to change that.