Skip to content

Molina Healthcare

Does Molina Healthcare cover Zepbound?

No. Molina Healthcare's policies on file exclude Zepbound for weight loss on Medicaid and ACA Marketplace plans.

Policy documents

  • Medicaid: Not covered. Zepbound (tirzepatide) is excluded from coverage for overweight/obesity per Social Security 1927(d)(3)(A), ...
  • ACA Marketplace: Not covered. Zepbound (tirzepatide) is excluded from coverage for overweight/obesity per Social Security 1927(d)(3)(A), ...

Earliest policy review June 11, 2026. How we verify · Check your exact plan

Full requirements: Zepbound for Weight Loss (2 plan types)

Applies to Medicaid plans.

Not covered

Zepbound (tirzepatide) is excluded from coverage for overweight/obesity per Social Security 1927(d)(3)(A), which excludes agents when used for anorexia, weight loss, or weight gain. Additionally, weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage. The policy states: '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.' State-specific exceptions exist for California Marketplace (morbid obesity with comprehensive weight loss program) and New Mexico Marketplace (medically necessary treatment of obesity and morbid obesity).

Exceptions

  • California_Marketplace: Coverage may be available when medically necessary for treatment of morbid obesity. Plans may require enrollment in a comprehensive weight loss program for a reasonable period prior to or concurrent with receiving the prescription drug. See Weight Management Therapy CA MMKP C28425-A.
  • New_Mexico_Marketplace: Prescription drugs medically necessary for the treatment of obesity and morbid obesity are covered. Phendimetrazine and phentermine are on formulary. See Weight Management Therapy NM MMKP C29220-A.

Policy note: This exclusion applies to all indications in states where weight loss drugs are a benefit exclusion. The policy explicitly cites Social Security Act 1927(d)(3)(A) statutory exclusion for Medicaid weight loss agents. The exclusion covers 'all indications, including but not limited to weight reduction and chronic weight management, weight reduction to treat moderate to severe obstructive sleep apnea.' California and New Mexico Marketplace have state-specific exceptions referenced in an Appendix with separate policies.

Policy effective December 11, 2025 · verified June 11, 2026 · source: Molina Healthcare Medicaid prior authorization policy · View policy document (PDF)

Applies to ACA Marketplace plans.

Not covered

Zepbound (tirzepatide) is excluded from coverage for overweight/obesity per Social Security 1927(d)(3)(A), which allows states to exclude agents when used for anorexia, weight loss, or weight gain. Additionally, weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage. In states where weight loss drugs are a benefit exclusion, Zepbound is considered a benefit exclusion for all indications including weight reduction and chronic weight management. State-specific exceptions apply for California Marketplace (morbid obesity with comprehensive weight loss program) and New Mexico Marketplace (medically necessary treatment of obesity and morbid obesity).

Exceptions

  • California_Marketplace: Coverage may be available when medically necessary for the treatment of morbid obesity. Plans may require enrollment in a comprehensive weight loss program for a reasonable period prior to or concurrent with prescription drug use. See Weight Management Therapy CA MMKP C28425-A.
  • New_Mexico_Marketplace: Prescription drugs medically necessary for the treatment of obesity and morbid obesity are covered. Treatments and medications solely for the purpose of weight reduction or control (except medically necessary treatment of morbid obesity and obesity) are not covered. See Weight Management Therapy NM MMKP C29220-A.

Policy note: This policy covers Zepbound for all indications and explicitly excludes it for weight loss/overweight/obesity as a benefit exclusion. The policy title includes 'NC' which may indicate 'Not Covered'. California and New Mexico Marketplace have state-specific exceptions that redirect to separate coverage criteria documents.

Policy effective December 11, 2025 · verified June 11, 2026 · source: Ed2 C6 F09 F1 D84 Ef1 A25 C2592 Fca62739 · View policy document (PDF)

Open on its own page →

Full requirements: Zepbound for Obstructive Sleep Apnea (OSA) (2 plan types)

Applies to Medicaid plans.

Not covered

Zepbound (tirzepatide) is considered a benefit exclusion for all indications in states where weight loss drugs are a benefit exclusion, explicitly including 'weight reduction to treat moderate to severe obstructive sleep apnea.' The policy states this exclusion applies to '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.'

Exceptions

  • California_Marketplace: State-specific exception may apply; see Weight Management Therapy CA MMKP C28425-A for criteria.
  • New_Mexico_Marketplace: State-specific exception may apply; see Weight Management Therapy NM MMKP C29220-A for criteria.

Policy note: The OSA indication for Zepbound is explicitly captured within the benefit exclusion language ('including but not limited to ... weight reduction to treat moderate to severe obstructive sleep apnea'). The mechanism of action for OSA is weight loss per the policy's background section. The clinical trial (NCT05412004) excluded patients with type 2 diabetes mellitus. The policy does not establish any affirmative coverage criteria because the drug is excluded. Policy number C29112-A. Original effective date 03/28/2025; revised Q4 2025.

Policy effective December 11, 2025 · verified June 11, 2026 · source: Molina Healthcare Medicaid prior authorization policy · View policy document (PDF)

Applies to ACA Marketplace plans.

Not covered

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. Weight loss drugs are benefit exclusions as outlined in the Marketplace Evidence of Coverage.

Exceptions

  • California_Marketplace: See Weight Management Therapy CA MMKP C28425-A for any applicable state-specific coverage criteria.
  • New_Mexico_Marketplace: See Weight Management Therapy NM MMKP C29220-A for any applicable state-specific coverage criteria.

Policy note: The OSA indication is explicitly grouped with weight loss indications and excluded under the same benefit exclusion language. The document states the exclusion applies to 'all indications, including but not limited to weight reduction and chronic weight management, weight reduction to treat moderate to severe obstructive sleep apnea.' The policy's 'REQUIRED MEDICAL INFORMATION' section contains only exclusion criteria and no coverage criteria, confirming this is a blanket exclusion policy for this plan type.

Policy effective December 11, 2025 · verified June 11, 2026 · source: Ed2 C6 F09 F1 D84 Ef1 A25 C2592 Fca62739 · View policy document (PDF)

Open on its own page →

If weight loss isn't covered on your plan

A prior authorization can't override a benefit exclusion. Ask Molina Healthcare about a formulary exception.

Questions people ask
Does Molina Healthcare cover Zepbound?
No. Molina Healthcare's policies on file exclude Zepbound for weight loss on Medicaid and ACA Marketplace plans.
How current is this information?
The oldest review date among the policies on this page is June 11, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Molina Healthcare: Mounjaro, Ozempic, Wegovy

Zepbound under other plans: BCBS Arizona, BCBS Michigan, BCBS Nebraska, BlueCross BlueShield of South Carolina, California Medicaid, Elevance Health, Excellus BCBS, Florida Blue

All insurance plans · All medications

Summary of Molina Healthcare's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.