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 PA |
| Obesity and morbid obesity (New Mexico marketplace only) | Covered with PA |
| Formulary placement across the 2026 Molina marketplace drug lists | Varies by plan |
Plan type: ACA Marketplace individual and family plans sold as Molina Marketplace. Each indication below lists the BMI and clinical thresholds, the prior-authorization documentation, and the published policy it comes from.
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 described 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. Molina's Medicaid plans are governed by each state's Medicaid drug list instead, and its Medicare plans by Part D rules. The same insurer in the same state can therefore 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 is six pages long and contains no criteria. 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 instead that "In states where weight loss drugs are a benefit exclusion, Wegovy (semaglutide) injection and tablets are considered a benefit exclusion for all indications", followed by "Weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage." The document then cites the federal list of drug categories a state may exclude, the first entry of which is agents used for weight loss. Because this is a benefit exclusion rather than a clinical denial, no BMI figure, comorbidity or documentation package changes the outcome. The document names two exceptions and directs reviewers to its appendix for California and New Mexico.
| Effective date | May 30 2026, first effective May 9 2024, next review due January 2027 |
Policy C27682-A. Source: Molina Healthcare Drug and Biologic Coverage Criteria, Wegovy (semaglutide) NC, Policy Number C27682-A, Current Effective Date 05/30/2026, Required Medical Information section. Official Molina criteria PDF published in the provider section of molinamarketplace.com (downloaded and read in full, all 6 pages). Molina's edge network blocks direct programmatic download, so the file was retrieved through a text-extraction proxy. The extraction was checked two ways. The identical document served under a second state path (New Mexico) returned byte-identical text including the same policy number and effective dates, and independent search-engine indexing of the same file returns the exclusion sentence in the same words.. Verified August 15, 2026.
Wegovy holds FDA indications beyond weight management, and Molina's marketplace document lists them and then excludes them. The full exclusion sentence reads that 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 document's Diagnosis field names the same three conditions, so the exclusion was written with the non-obesity indications in view. Its FDA-Approved Uses section separately sets out the cardiovascular indication and the noncirrhotic MASH indication for stages F2 to F3 fibrosis, and its background section summarizes the SELECT cardiovascular outcomes trial.
| Effective date | May 30 2026 |
Policy C27682-A. Source: Molina Healthcare Drug and Biologic Coverage Criteria, Wegovy (semaglutide) NC, Policy Number C27682-A, Diagnosis, Required Medical Information and FDA-Approved Uses sections. Official Molina criteria PDF published at molinamarketplace.com (downloaded and read in full). Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026.
The Zepbound document is built the same way and reaches the same place. Its criteria fields read N/A and 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, including the finding that patients on Zepbound achieved a significant reduction in the apnea-hypopnea index against placebo at 52 weeks, and it directs reviewers to the appendix for California and New Mexico.
| Effective date | December 11 2025, first effective March 28 2025, next review due October 2026 |
Policy C29112-A. Source: Molina Healthcare Drug and Biologic Coverage Criteria, Zepbound (tirzepatide) NC, Policy Number C29112-A, Current Effective Date 12/11/2025, Required Medical Information and Background sections. Official Molina criteria PDF published in the provider section of molinamarketplace.com (downloaded and read in full, all 5 pages). Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026.
We read the 2026 agreements for two of Molina's larger marketplace states in full. Both carry an identical Non-Covered Drugs list, and both include the line "Weight loss drugs, or diabetic drugs when used off-label to lose weight instead of treating diabetes." Neither attaches a medical necessity exception to that line, which is the drafting difference that separates these states from California and New Mexico. The agreements also describe the appeal position. Molina commits in the same section not to deny an off-label request solely 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. Official Molina member agreement PDF published at molinamarketplace.com (downloaded and read in full). Cross-read against the Molina Healthcare of Florida 2026 marketplace agreement, document FL26EOCE_OX, at the same domain, which carries the identical Non-Covered Drugs bullet. Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026.
California is the state where Molina's marketplace contract itself carves out an exception. The 2026 California agreement excludes "Weight loss drugs, unless approved by Medical Necessity for morbid obesity (Class III Obesity)", and the criteria for that exception live in a separate California-only policy. The criteria are written for morbid obesity, so a member seeking Zepbound for sleep apnea or Wegovy for cardiovascular risk is not on this pathway even in California. The continuation rule requires 10 percent of baseline body weight by week 24, and the policy says the drug must be discontinued if that is not met. The California policy also predates 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, or BMI 35 or higher for members with an obesity-related health condition, which the policy exemplifies as diabetes, impaired glucose tolerance, dyslipidemia, hypertension, coronary heart disease or sleep apnea |
| Step therapy | For members with type 2 diabetes, a documented trial and inadequate response to all formulary GLP-1 or GLP-1/GIP agents indicated for diabetes. The policy defines inadequate response as failing to reach the expected A1c lowering goal while adherent to therapy and failing to reach the member's individualized therapy goals. |
| Continuation | At least 10 percent of baseline body weight lost or maintained, plus prescriber attestation that the member remains compliant with a formalized weight management program. Authorizations past 12 months of continuous Saxenda or Wegovy therapy need documentation of weight maintenance and continued program participation. The policy sets a hard stop, that if the member has not lost at least 10 percent of baseline body weight by week 24 the drug must be discontinued. |
| 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:
- Prescriber attestation that the member attempted weight loss in a formalized weight management program covering diet, exercise and behavior modification, with continuing follow-up, for at least 3 months before drug therapy
- Prescriber attestation that the member is currently enrolled in a supervised weight loss program that encourages behavioral modification, increased physical activity and non-pharmacologic weight loss
- Documentation of baseline weight taken within the last 30 to 60 days
- Prescriber attestation that the member has no FDA-labeled contraindications left unaddressed in the submitted documentation
- 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
Policy C28425-A. Source: Molina Healthcare Drug and Biologic Coverage Criteria, Medical Necessity for Morbid obesity (Class III Obesity) CA MKP ONLY, Policy Number C28425-A, Required Medical Information and Continuation of Therapy sections. Official Molina California-only criteria PDF published in the California provider section of molinamarketplace.com (downloaded and read in full, all 7 pages). The contract-level exception was read from the Molina Healthcare of California 2026 marketplace agreement, document CA26EOCE_M1, Non-Covered Drugs section, at the same domain. Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026.
New Mexico is the one state in our sweep where a Molina marketplace member can find one of these drugs on the formulary. The exception is written into the contract first. The New Mexico 2026 agreement carries the same Non-Covered Drugs bullet as Texas and Florida but 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 morbid obesity and obesity, and that medically necessary prescription drugs for the treatment of obesity and morbid obesity are also covered. The formulary follows the contract only part way. New Mexico's 2026 marketplace formulary carries an Anti-Obesity GIP and GLP-1 Receptor Agonists heading listing all six Zepbound strengths in three presentations at Tier 4 with prior authorization, and lists phentermine and phendimetrazine at Tier 1 under anorexiants. Wegovy is not on it.
| Continuation | Not published. Molina's Wegovy and Zepbound criteria documents point New Mexico requests to a separate policy, Weight Management Therapy NM MMKP C29220-A, which Molina does not publish on its 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. Official Molina marketplace formulary PDF (downloaded and searched in full for every Wegovy, Zepbound, Saxenda, tirzepatide, semaglutide, Qsymia, Contrave, orlistat, phentermine and phendimetrazine string). The contract language was read from the Molina Healthcare of New Mexico 2026 marketplace agreement, document NM26EOCE, Non-Covered Drugs and Weight Loss Programs sections, at molinamarketplace.com. The missing criteria document was confirmed by reading Molina's New Mexico marketplace provider Drug List index, which links only to C27682-A and C29112-A. Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026. This row is marked lower confidence: the policy document was confirmed at its public URL but served as an unreadable file, so the policy number and framework were cross-checked against secondary sources.
We read the formularies to test the exclusion rather than to establish it, because a drug can be absent from a list and still be payable through an exception. On Molina marketplace plans it cannot, and the formularies say so themselves. The front matter answers the question directly under the 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 is the clearest illustration of the pattern. It has an anti-obesity category heading, no anti-obesity drug beneath it, and the diabetes GLP-1 agents Ozempic, Rybelsus and Trulicity 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 an ADHD, anti-narcolepsy, anti-obesity and anorexiants category heading that contains no anti-obesity drug at all
Source: Molina Marketplace Texas 2026 Formulary, 161 pages, formulary introduction and the ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants section. Official Molina marketplace formulary PDFs (each downloaded and searched in full for every Wegovy, Zepbound, Saxenda, tirzepatide, semaglutide, Qsymia, Contrave, orlistat, phentermine and phendimetrazine string). Cross-checked the same way against the 2026 Molina marketplace formularies for California, Florida, New Mexico, Ohio, Utah and Washington at molinahealthcare.com and molinamarketplace.com. Retrieved through the same text-extraction proxy described above, Molina's edge network returns 403 to direct download.. Verified August 15, 2026.
Recent change: The Wegovy exclusion has been through four rounds of revision and has survived all of them. Molina's own revision log inside C27682-A shows the criteria created in Q2 2024, then revised in Q1 2025 (appendix and contraindications), Q4 2025 (diagnosis and required medical information), Q1 2026 (products affected, required medical information, route of administration, FDA-approved uses, other special considerations, dosage forms and references) and Q2 2026 (products affected, dosage forms and references). Required Medical Information is the section that holds the exclusion sentence, and it was rewritten twice without the exclusion coming out. The revisions did extend the exclusion's reach. The current document lists Wegovy HD 7.2 mg and the Wegovy tablet strengths among the affected dosage forms, so the newer formulations are excluded on the same terms as the original injection. The Zepbound document C29112-A was created in Q1 2025 and revised once, in Q4 2025, touching the appendix, contraindications, dosage forms and references.
Important exclusions
- A benefit exclusion cannot be turned into coverage through the formulary exception route. The 2026 marketplace formularies state it directly, that non-covered drugs such as benefit exclusions are not covered at all and cannot be approved for coverage by formulary exception
- The exclusion is drafted to capture the non-weight-loss indications as well. The Wegovy document names cardiovascular event risk reduction and metabolic dysfunction-associated steatohepatitis inside the excluded list, and the Zepbound document names moderate to severe obstructive sleep apnea
- Both criteria documents make the answer conditional on the state, so the governing document for any individual member is the member agreement for that state and plan year rather than the criteria PDF
- Absence from a Molina formulary is not the same finding as the exclusion. We treat the exclusion language in the member agreement and the criteria documents as the coverage verdict, and treat the formulary sweep separately as evidence of what a pharmacy would fill without an authorization
- Molina is reducing its marketplace business. Marketplace membership was 283,000 at June 30 2026, down 407,000 from a year earlier, and Molina's Form 10-Q for the quarter ended June 30 2026 reports it expects roughly 250,000 members by the end of 2026 with further reductions planned for 2027, so a plan available this year may not be offered 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 the full coverage picture, denial reasons, and the four appeal pathways at GLP-1 insurance coverage.
- If the prior-authorization request is denied, the appeal letter library has templates by denial reason, covering peer-to-peer review, Level 1 and Level 2 internal appeal, and external review.
- 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. Some participants get a placebo, decided at random.
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
Each page is built from a published payer policy document, government statute, or independent formulary analysis (KFF). Every indication row carries the source URL and the date we verified it. Where a payer's policy PDF was confirmed at its public URL but served as an unreadable binary, the policy number and coverage framework were cross-checked against secondary sources; those rows are marked lower confidence. Commercial coverage often depends on whether an employer elected the weight-management benefit. 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.
