Sunshine Health Medicaid does cover Ozempic, but only when it’s prescribed for an FDA-approved use tied to type 2 diabetes. If you need semaglutide for blood sugar control, to reduce cardiovascular risk alongside established heart disease, or to slow kidney function decline in chronic kidney disease, the plan will pay for it, typically after prior authorization. If the prescription is written for weight loss, Florida Medicaid will not cover it, and neither will Sunshine Health.
When Sunshine Health Will Pay for Ozempic
Sunshine Health follows the Florida Agency for Health Care Administration’s Preferred Drug List rather than keeping an independent formulary.1Sunshine Health. Preferred Drug List Updates Ozempic sits on that state formulary for diabetes.2Real Chemistry. State-by-State Analysis of Medicaid Coverage for GLP-1 Weight Loss
The FDA has approved Ozempic for three uses in adults with type 2 diabetes: improving glycemic control as an add-on to diet and exercise; reducing the risk of heart attack, stroke, and cardiovascular death in patients who also have established heart disease; and reducing the risk of sustained kidney function decline, end-stage kidney disease, and cardiovascular death in patients who also have chronic kidney disease. The kidney indication was added in January 2025.3U.S. Food and Drug Administration. Ozempic Prescribing Information
A prescription tied to any of those indications falls inside what Florida Medicaid is required to cover for GLP-1 medications.4KFF. Medicaid Coverage of and Spending on GLP-1s
Why Weight Loss Prescriptions Aren’t Covered
Federal law lets state Medicaid programs leave weight-loss drugs off their formularies, and Florida takes that option. GLP-1s prescribed purely for obesity, including Wegovy, Zepbound, and Saxenda, are not covered.2Real Chemistry. State-by-State Analysis of Medicaid Coverage for GLP-1 Weight Loss Ozempic itself is not FDA-approved for weight loss; Wegovy is the semaglutide product that carries the obesity indication.3U.S. Food and Drug Administration. Ozempic Prescribing Information
In practice, this means an off-label Ozempic prescription written solely for weight management will not be paid for by Sunshine Health. The prescription has to be tied to one of the drug’s on-label diabetes, cardiovascular, or kidney indications.2Real Chemistry. State-by-State Analysis of Medicaid Coverage for GLP-1 Weight Loss
Getting Prior Authorization
GLP-1 medications in Florida Medicaid generally require prior authorization. Your prescriber submits the request and documents that you meet the clinical criteria for the drug. For Sunshine Health, prior authorization requests go to:
- Phone: 1-866-399-0928
- Fax: 1-833-546-1507
- CMS Health Plan prior authorizations: 1-833-705-1351 (fax: 1-888-865-6531)
Sunshine Health points providers to its prior authorization criteria page for the current clinical requirements.5Sunshine Health. Medicaid Supplemental Preferred Drug List Ozempic does not have its own standalone state form; a prescriber working through the fee-for-service system would use the Miscellaneous Pharmacy Prior Authorization Request form maintained by AHCA.6Florida Agency for Health Care Administration. Pharmacy Prior Authorization Forms
If Your Ozempic Is Denied
A denial isn’t the end of the road. Sunshine Health has a structured appeals process, and after that you can take the dispute to the state.
File a Plan Appeal Within 60 Days
You have 60 days from the denial notice to file an appeal with Sunshine Health. Options:
- Phone: 1-866-796-0530 (TTY: 1-800-955-8770)
- Mail: P.O. Box 459087, Fort Lauderdale, FL 33345-9087
- Fax: 1-866-534-5972
- Email: Sunshine_Appeals@centene.com
The plan acknowledges receipt within five business days and issues a decision within 30 days.7Sunshine Health. Complaints and Appeals
For pharmacy-specific appeals, Sunshine Health runs a dedicated line at 1-800-460-8988 (TTY: 1-800-955-8770), Monday through Friday, 8:00 a.m. to 10:30 p.m. Eastern. The fax for non-specialty or retail medications is 1-888-865-6531; for specialty or buy-and-bill medications it is 1-844-235-5091.8Sunshine Health. Pharmacy Appeals
Ask for an Expedited Appeal If Delay Would Hurt You
If your provider believes waiting 30 days would seriously jeopardize your health, you can request an expedited appeal. Sunshine Health must then respond within 48 hours. If the plan decides your situation does not qualify for the expedited track, it notifies you within 24 hours by phone and within two days in writing, and the appeal moves back to the standard 30-day timeline.7Sunshine Health. Complaints and Appeals
Keep Your Medication During the Appeal
If you’re already on Ozempic and the plan is trying to stop covering it, you can ask that coverage continue while your appeal is pending. The request has to be filed within 10 days of the denial notice or before the effective date of the change. If you lose the appeal, you may have to pay for the medication you received during that stretch.7Sunshine Health. Complaints and Appeals
Request a Medicaid Fair Hearing
Once you’ve gone through the plan-level appeal, you have 120 days from the final decision to request a Medicaid Fair Hearing through AHCA:
- Phone: 1-877-254-1055
- Fax: 1-239-338-2642
- Email: MedicaidFairHearingUnit@ahca.myflorida.com
- Mail: P.O. Box 7237, Tallahassee, FL 32314-7237
Include your name, member number, Medicaid ID, a phone number where you can be reached, and any medical records that support your request. Title XXI MediKids members cannot use the Medicaid Fair Hearing process and must instead request a state-level review within 30 days of the plan’s appeal decision.7Sunshine Health. Complaints and Appeals