Coverage at a glance
| Indication | Coverage |
|---|---|
| Obesity / chronic weight management (Wegovy) | Not covered |
| Cardiovascular risk reduction and liver disease (Wegovy) | Not covered |
| Obesity and obstructive sleep apnea (Zepbound) | Not covered |
| What the member agreement says (Texas and Florida) | Not covered |
| Morbid obesity, Class III (California marketplace only) | Covered with prior authorization |
| Obesity and morbid obesity (New Mexico marketplace only) | Covered with prior authorization |
| Formulary placement across the 2026 Molina marketplace drug lists | Varies by plan |
If your plan denies coverage, two cash programs to check.
No insurance needed.
- Strut Health$149 a month, with auto-refillcompounded semaglutideCheck price →You pick Weight Loss, then a five-minute online visit
- Shed$199 a monthcompounded semaglutideCheck price →Every medication is listed with a starting price
Cheapest GLP-1 without insurance compares the three cash routes. Cheapest GLP-1 ranks every cash price on the chart.
Prior authorization: the plan reviews the prescription before it pays. Step therapy: the plan wants a cheaper drug tried first.
Not on a Molina marketplace plan in a state whose member agreement lists weight loss drugs as non-covered. Molina writes a criteria document for Wegovy and one for Zepbound, and neither of them holds a single clinical rule. Every field that would carry a BMI number, an age limit, a step therapy rule or an approval length reads N/A. In their place sits one sentence, calling the drug a benefit exclusion for all indications. That sentence names three uses inside the exclusion: to lower cardiovascular risk, to treat liver disease, and to treat sleep apnea. Both documents make the answer depend on the state. So we read four 2026 member agreements. Texas and Florida list weight loss drugs under Non-Covered Drugs, with no exception attached. California and New Mexico are the exceptions, and each one is written into that state's own member agreement. This answer covers ACA Marketplace individual and family plans sold as Molina Marketplace.
Source: Molina policy C27682-A. Checked August 15, 2026.
Where your plan lists it. Tier 4 cost sharing for Zepbound, against Tier 1 for phentermine and phendimetrazine. Source: Molina Marketplace New Mexico 2026 Formulary, Anorexiants Non-Amphetamine and Anti-Obesity GIP and GLP-1 Receptor Agonists sections.
What it costs once they say yes. With commercial insurance the manufacturer savings card takes Wegovy or Zepbound to as little as $25 a month. Your plan sets the copay before the card applies. What Wegovy costs with your plan. What Zepbound costs with your plan.
Three lines of business, one of them. Molina runs three separate lines of business, and this page is only about one of them. The marketplace plans here are governed by the member agreement Molina files with each state, and by two corporate criteria documents, C27682-A for Wegovy and C29112-A for Zepbound. Each state's Medicaid drug list governs Molina's Medicaid plans instead. Part D rules govern its Medicare plans. So the same insurer, in the same state, can reach different answers on the same drug, depending on which card the member holds. New Mexico is the live example. Our Medicaid pages carry the Medicaid answer.
Coverage by indication
Molina's marketplace criteria document for Wegovy runs six pages, and it holds no criteria at all. Continuation of Therapy, Duration of Approval, Prescriber Requirements, Age Restrictions and Quantity all read N/A. The Required Medical Information section, where thresholds would normally sit, says this instead. "In states where weight loss drugs are a benefit exclusion, Wegovy (semaglutide) injection and tablets are considered a benefit exclusion for all indications". It follows that with "Weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage." The document goes on to cite the federal list of drug categories a state is allowed to exclude. The first entry on that list is agents used for weight loss. This is a benefit exclusion, not a clinical denial. So no BMI figure, no other condition and no paperwork changes the outcome. The document names two exceptions, and it sends reviewers to its appendix for California and New Mexico.
| Effective date | May 30 2026, first effective May 9 2024, next review due January 2027 |
Source: Molina policy C27682-A. Molina's own criteria PDF, all 6 pages, read in full.
Wegovy holds FDA uses beyond weight management. Molina's marketplace document lists them, and then excludes them. The full exclusion sentence says Wegovy is a benefit exclusion "for all indications, including but not limited to weight reduction and chronic weight management, weight reduction to lower risk for repeat cardiovascular event in individuals with history of prior heart attack or stroke, metabolic dysfunction-associated steatohepatitis, and so on." The Diagnosis field in that document names the same three conditions, so the exclusion was written with the non-obesity indications in view. Its FDA-Approved Uses section sets out the cardiovascular indication and the noncirrhotic MASH indication for stages F2 to F3 fibrosis. Its background section sums up the SELECT cardiovascular outcomes trial.
| Effective date | May 30 2026 |
Source: Molina policy C27682-A. Molina's own criteria PDF, read in full.
The Zepbound document is built the same way, and it lands in the same place. Its criteria fields read N/A. Its Required Medical Information section says that "In states where weight loss drugs are a benefit exclusion, Zepbound (tirzepatide) is considered a benefit exclusion for all indications, including but not limited to weight reduction and chronic weight management, weight reduction to treat moderate to severe obstructive sleep apnea, and so on." The document goes on to describe the SURMOUNT-OSA trial program in its background section. It records that patients on Zepbound achieved a significant reduction in the apnea-hypopnea index against placebo at 52 weeks. And it sends reviewers to the appendix for California and New Mexico.
| Effective date | December 11 2025, first effective March 28 2025, next review due October 2026 |
Source: Molina policy C29112-A. Molina's own criteria PDF, all 5 pages, read in full.
We read the 2026 agreements for two of Molina's larger marketplace states in full. Both carry the same Non-Covered Drugs list. Both include the line "Weight loss drugs, or diabetic drugs when used off-label to lose weight instead of treating diabetes." Neither one attaches a medical necessity exception to that line. That drafting difference is what separates these two states from California and New Mexico. The agreements also set out the appeal position. In the same section, Molina commits not to deny an off-label request just because the use sits outside the FDA label. But that protection applies to drugs treating a covered condition.
| Effective date | 2026 plan year |
Source: Molina Healthcare of Texas Off-Exchange 2026 Agreement and Evidence of Coverage, document TX26EOCE_SM, Non-Covered Drugs section. Molina's own member agreement PDF, read in full.
California is the one state where Molina's own marketplace contract carves out an exception. The 2026 California agreement excludes "Weight loss drugs, unless approved by Medical Necessity for morbid obesity (Class III Obesity)". The criteria for that exception sit in a separate California-only policy. Those criteria are written for morbid obesity. So a member seeking Zepbound for sleep apnea, or Wegovy for cardiovascular risk, is not on this route, even in California. The continuation rule requires 10 percent of baseline body weight gone by week 24, and the policy says the drug must be stopped if that is not met. The California policy is also older than the exception it now serves. Its next review was due by July 2025, and the Wegovy criteria document that points to it took effect in May 2026. So it is being relied on past its own review date.
| BMI threshold | BMI 40 or higher. BMI 35 or higher also works for a member with an obesity-related health condition. The policy gives its own examples: diabetes, impaired glucose tolerance, dyslipidemia, hypertension, coronary heart disease or sleep apnea |
| Step therapy | For members with type 2 diabetes, a documented trial of all formulary GLP-1 or GLP-1/GIP agents indicated for diabetes, with an inadequate response to each. The policy defines an inadequate response as two failures together. The member failed to reach the expected A1c lowering goal while sticking with the drug. The member also failed to reach their own individualized therapy goals. |
| Continuation | At least 10 percent of baseline body weight lost, or kept off. The prescriber also has to confirm the member is sticking with a formalized weight management program. An authorization past 12 months of continuous Saxenda or Wegovy therapy needs documented weight maintenance and continued program participation. The policy sets a hard stop too. If the member has not lost at least 10 percent of baseline body weight by week 24, the drug must be stopped. |
| Authorization length | 6 months initial, 6 months on continuation |
| Effective date | October 16 2024, next review was due July 2025 |
What the prior authorization needs:
- The prescriber confirms the member tried to lose weight in a formalized weight management program for at least 3 months before the drug. That program has to cover diet, exercise and behavior change, with follow-up along the way
- The prescriber confirms the member is now in a supervised weight loss program. That program has to encourage behavior change, more physical activity, and weight loss without drugs
- Documentation of baseline weight taken within the last 30 to 60 days
- The prescriber confirms the member has no FDA-labeled contraindication left unaddressed in the paperwork sent in
- Age 12 or older for Wegovy, Saxenda, Qsymia and orlistat, and 18 or older for Zepbound and the rest of the list
- Quantity limits of 5 Wegovy pens per 30 days at a maximum of 2.4 mg, and 4 Zepbound pens per 28 days at a maximum of 15 mg once weekly
Source: Molina policy C28425-A. Molina's own criteria PDF for California, all 7 pages, read in full.
New Mexico is the one state in our sweep where a Molina marketplace member can find one of these drugs on the drug list. The exception is written into the contract first. The New Mexico 2026 agreement carries the same Non-Covered Drugs bullet that Texas and Florida carry. But it adds five words to the end of it, "unless stated otherwise in this agreement". And the agreement does state otherwise. Its Weight Loss Programs section says Molina covers dietary evaluations and counseling for the medical management of obesity and morbid obesity. It goes on to say that medically necessary prescription drugs to treat obesity and morbid obesity are covered as well. The drug list follows the contract only part way. New Mexico's 2026 marketplace drug list carries an Anti-Obesity GIP and GLP-1 Receptor Agonists heading. Under it sit all six Zepbound strengths, in three presentations, at Tier 4, with prior authorization. Under anorexiants it lists phentermine and phendimetrazine at Tier 1. Wegovy is not on it.
| Continuation | Not published. Molina's Wegovy and Zepbound criteria documents send a New Mexico request off to a policy of its own. It is called Weight Management Therapy NM MMKP C29220-A. Molina does not publish it on the New Mexico provider drug criteria index. |
| Effective date | 2026 plan year |
What the prior authorization needs:
- Prior authorization on every Zepbound presentation listed
- Quantity limit of 2.4 mL per 28 days for the Zepbound KwikPen, and 2 mL per 28 days for the single-dose vial and the single-dose auto-injector
- Tier 4 cost sharing for Zepbound, against Tier 1 for phentermine and phendimetrazine
Source: Molina Marketplace New Mexico 2026 Formulary, Anorexiants Non-Amphetamine and Anti-Obesity GIP and GLP-1 Receptor Agonists sections. Molina's own marketplace drug list PDF. Lower confidence: the policy file would not open at the payer's own address, so the policy number and rules were checked against a second source.
We read the drug lists to test the exclusion, not to establish it. A drug can be absent from a list and still be payable through an exception. On Molina marketplace plans it cannot, and the drug lists say so themselves. The front matter answers the question directly, under a heading asking whether any products are not covered at all. "Non-covered drugs or other products such as benefit exclusions are not covered at all. They cannot be approved for coverage by formulary exception. Your plan does not cover certain types of drugs that are listed as benefit exclusions in the plan policy." The Texas list shows the pattern most clearly. It carries an anti-obesity category heading, with no anti-obesity drug under it. The diabetes GLP-1 agents Ozempic, Rybelsus and Trulicity are listed separately, at Tier 3, with step therapy and quantity limits.
| Effective date | 2026 plan year |
What the prior authorization needs:
- Seven 2026 Molina marketplace formularies were searched in full: California, Florida, New Mexico, Ohio, Texas, Utah and Washington
- Wegovy appears on none of the seven
- Zepbound appears on one, New Mexico, at Tier 4 with prior authorization and a quantity limit
- Saxenda, Qsymia, Contrave and orlistat appear on none of the seven
- Phentermine and phendimetrazine appear only on the New Mexico list, at Tier 1
- Six of the seven carry a category heading for ADHD, anti-narcolepsy, anti-obesity and anorexiants, with no anti-obesity drug under it at all
Source: Molina Marketplace Texas 2026 Formulary, 161 pages, formulary introduction and the ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants section. Molina's own marketplace drug list PDFs.
Recent change: The Wegovy exclusion has been through four rounds of revision, and it has survived all of them. Molina's own revision log inside C27682-A shows the criteria created in Q2 2024. Q1 2025 touched the appendix and the contraindications. The Q4 2025 round reached the diagnosis and the Required Medical Information section. Q1 2026 was the widest of the four, taking in the products affected, the required medical information, the route of administration, the FDA-approved uses, other special considerations, the dosage forms and the references. Q2 2026 came back to three of those: the products affected, the dosage forms and the references. Required Medical Information is the section that holds the exclusion sentence. It was rewritten twice, and the sentence never came out. The revisions did widen its reach. The document now lists Wegovy HD 7.2 mg and the Wegovy tablet strengths among the dosage forms affected. So the newer forms are excluded on the same terms as the original shot. The Zepbound document, C29112-A, was created in Q1 2025 and revised once, in Q4 2025. That round touched the appendix, the contraindications, the dosage forms and the references.
Ozempic and Mounjaro on Molina plans
Ozempic and Mounjaro are approved for type 2 diabetes, not weight loss.
Does Molina cover Ozempic?
Yes, with prior approval. Molina pays for Ozempic once your prescriber gets the plan to sign off.
Yes. On Molina's ACA Marketplace plans, Ozempic is covered for type 2 diabetes. Ozempic is semaglutide, and it is listed under GLP-1 receptor agonists on the drug list. Molina publishes a separate drug list in each state, so the tier and the cost share can differ. On the 2026 Texas and Washington lists we checked, it sits at tier 3, with step therapy and a quantity limit. So a member generally has to try a preferred diabetes drug first. The FDA approved Ozempic for type 2 diabetes only, and Molina does not cover it for weight loss. The weight-loss semaglutide is Wegovy. Neither Wegovy nor the other weight-loss GLP-1s are on the Marketplace drug list.
Checked August 27, 2026.
What Molina requires for Ozempic
| Step therapy | Required |
What the prior authorization needs:
- Listed on the Marketplace formulary at tier 3 (non-preferred brand cost share)
- Step therapy applies: a preferred diabetes drug must be tried first
- Quantity limit applies: 3 mL per 25 days for the 0.25, 0.5 and 1 mg pens, 3 mL per 28 days for the 2 mg pen, and 1 tablet per day for oral Ozempic
- Prescribed for type 2 diabetes. Ozempic is grouped with the GLP-1 receptor agonists, not with the weight-loss drugs, and it is not covered for weight loss
Source: Molina Healthcare of Texas Marketplace 2026 Formulary (List of Covered Drugs), current as of July 1, 2026. The plan's own covered-drug list.
Does Molina cover Mounjaro?
Yes on some plans. Molina publishes a different drug list for each plan it sells, so two people with the same insurer can get different answers.
Molina covers Mounjaro for type 2 diabetes, the use the FDA approved. The plan has to sign off, and quantity limits apply. Molina runs a separate Marketplace drug list and a separate Medicaid drug list in each state. So the tier, any step-therapy rule, and the exact limits differ by plan and by location. Mounjaro is not covered for weight loss. That use belongs to Zepbound, which Molina lists in a separate anti-obesity section and restricts. Check the drug list for your own state plan before you count on coverage.
Checked August 27, 2026.
What Molina requires for Mounjaro
| Step therapy | Not required |
What the prior authorization needs:
- Prior authorization required
- Covered for type 2 diabetes only, the use the FDA approved. Not covered for weight loss
- Quantity limits apply. The verified Michigan Medicaid list caps Mounjaro at 90 mL per fill, up to a 102-day supply
- The tier, the step therapy and the limits all differ by state, and by whether the plan is Marketplace or Medicaid
Source: Molina Healthcare of Michigan Preferred Drug List (Formulary), August 2026 to October 2026. The plan's own covered-drug list. Lower confidence: the policy file would not open at the payer's own address, so the policy number and rules were checked against a second source.
Important exclusions
- A benefit exclusion is not something you can turn into coverage by asking for an exception. The 2026 marketplace drug lists say so in so many words. A non-covered drug, such as a benefit exclusion, is not covered at all, and it cannot be approved for coverage by formulary exception
- The exclusion is drafted to catch the non-weight-loss uses as well. The Wegovy document puts two of them on the excluded list: cardiovascular event risk reduction, and metabolic dysfunction-associated steatohepatitis, a liver disease. The Zepbound document puts moderate to severe obstructive sleep apnea on its list
- Both criteria documents make the answer depend on the state. So the document that rules for any one member is the member agreement for that state and plan year, and not the criteria PDF
- Being absent from a Molina drug list is not the same finding as the exclusion. We treat the exclusion language, in the member agreement and in the criteria documents, as the coverage verdict. We treat the drug list sweep separately, as evidence of what a pharmacy would fill without an authorization
- Molina is cutting back the marketplace side of its business. Membership there was 283,000 at June 30 2026, down 407,000 from a year earlier. Molina's Form 10-Q for the quarter ended June 30 2026 says it expects roughly 250,000 members by the end of 2026, with further cuts planned for 2027. So a plan you can buy this year may not be sold next year
What to do next
If you qualify under one of the covered indications above, prior authorization is the path. Match the documentation in the requirements list then have your prescriber submit it. Plans that approve reassess at renewal, so know your long-term maintenance dose before you start.
- Browse the prior-authorization letter library for a template that matches your plan and indication.
- Read why plans say no and the four ways to appeal in the GLP-1 insurance guide.
- Your plan may treat another GLP-1 differently. The Molina coverage check lists all 3, with the source for each.
- If the plan denies it, the appeal letter library has a template for each reason a plan gives. That covers the peer-to-peer call with a plan doctor, the Level 1 and Level 2 appeals inside the plan, and the outside review that follows them.
- If your plan does not cover the indication you need, compare cash prices in the cost guide or check whether a clinical trial near you fits. Neither one goes through your insurer. Clinical trials cost nothing and many pay you for your time.
What it costs without insurance
The programs below bill you directly. Prices checked every Monday.
Frequently asked questions
Does Molina cover Wegovy for weight loss?
Not in Texas or Florida, whose 2026 member agreements list weight loss drugs as non-covered. Molina's marketplace criteria document for Wegovy has no clinical criteria in it. The fields for BMI, age, step therapy, quantity and approval duration all read N/A, and the section that would hold them says Wegovy is a benefit exclusion for all indications where weight loss drugs are excluded by the plan. The Texas and Florida 2026 member agreements list weight loss drugs under Non-Covered Drugs with no exception attached. Because that is a benefit exclusion and not a clinical rule, a higher BMI or an added comorbidity does not change the answer, and the formularies state that a benefit exclusion cannot be approved through the formulary exception route. Wegovy does not appear on any of the seven 2026 Molina marketplace formularies we searched.
Does Molina cover Zepbound for sleep apnea?
Not in the states we read. Molina closed that indication by name rather than leaving it unaddressed. The marketplace criteria document for Zepbound says the drug is a benefit exclusion for all indications, and it spells out that this includes weight reduction to treat moderate to severe obstructive sleep apnea. The same document then describes the trial evidence for that indication in its background section, including the reduction in the apnea-hypopnea index against placebo at 52 weeks. New Mexico is the only state in our sweep whose marketplace formulary lists Zepbound, at Tier 4 with prior authorization, and the New Mexico contract exception is written for obesity and morbid obesity rather than for sleep apnea.
Why is Ozempic on the Molina formulary when Wegovy is not?
Ozempic and Rybelsus are semaglutide too. They sit on the Texas 2026 marketplace formulary at Tier 3 because they are prescribed for type 2 diabetes. Wegovy carries weight management indications, so on a Molina marketplace plan it falls into the excluded category. The member agreements make the boundary explicit by excluding "Weight loss drugs, or diabetic drugs when used off-label to lose weight instead of treating diabetes", which blocks the workaround of writing a diabetes GLP-1 for a member who does not have diabetes.
What BMI does Molina require for GLP-1 coverage?
There is no BMI that unlocks coverage in the states whose member agreement excludes weight loss drugs, because the block is a benefit exclusion rather than a threshold. California is the state with published numbers. Its marketplace-only criteria require a BMI of 40 or higher, or 35 or higher for members with an obesity-related condition such as diabetes, impaired glucose tolerance, dyslipidemia, hypertension, coronary heart disease or sleep apnea. California's continuation test is set at 10 percent of baseline body weight, and the policy states that if the member has not lost at least 10 percent by week 24 the drug must be discontinued. New Mexico's thresholds are referenced in Molina's documents as policy C29220-A but are not published.
My Molina plan covers Zepbound, so why does this page say excluded?
Check which Molina plan you have, because Molina sells three kinds and they do not follow the same rules. This page covers Molina Marketplace plans bought on an exchange. Molina also runs Medicaid plans in many states, and those follow each state's Medicaid drug list, which can reach a different answer on the same drug in the same state. New Mexico shows both directions at once. Molina's New Mexico marketplace formulary lists Zepbound with prior authorization, while New Mexico Medicaid excludes weight loss GLP-1s under the state preferred drug list. Molina's Medicare plans run on Part D rules, which is a third set again. Your member ID card names the plan.
Coverage for other payers
See the full payer coverage index for every plan we have sourced.
How we built this page
Every page here comes from the payer's own policy, a federal law, or KFF's plan research. Each row links its source and gives the date we read it. Some plan files load at the address the payer gives but will not open. We check those against a second source and mark the row lower confidence. Job-based plans also choose whether to add the weight-drug benefit at all, so those rows say varies by plan rather than a flat yes.
This is reference information, not medical or legal advice, and not a guarantee of coverage. GLP-1 coverage policies change often. Always confirm the current policy with your insurer using the number on your card before you rely on this page. If your experience differs from what is shown here, email hello@glpchart.com with the details and we will re-verify.
