Molina Healthcare · Weight Loss

Molina Healthcare coverage for Zepbound (Weight Loss)

Medicaid

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: Pa policy

ACA Marketplace

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: ED2C6F09F1D84EF1A25C2592FCA62739.ashx

All Zepbound policies under Molina Healthcare · Check your card