Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Standard pathway: prior oral antidiabetic agent use
All of:
- Age ≥ 18 years
- Diagnosis of type 2 diabetes in the last 365 days
- History of an oral antidiabetic agent for 14 consecutive days in the last 365 days
- No history of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 in the last 730 days
- No history of ESRD services (CPT codes) in the last 730 days
- HbA1c test in the last 180 days
- No concurrent therapy with a GLP-1 RA containing agent
Alternative pathway: history of requested medication (stable therapy)
All of:
- Age ≥ 18 years
- Diagnosis of type 2 diabetes in the last 365 days
- History of the requested medication for 14 consecutive days in the last 365 days
- No history of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 in the last 730 days
- No history of ESRD services (CPT codes) in the last 730 days
- HbA1c test in the last 180 days
- No concurrent therapy with a GLP-1 RA containing agent
Documentation to bring
- Type 2 diabetes diagnosis (ICD-10 code from Table 3) within last 365 days
- History of oral antidiabetic agent for 14 consecutive days in the last 365 days (Table 4) OR history of requested medication for 14 consecutive days in the last 365 days (Table 5)
- HbA1c test (CPT 83036 or 83037) within the last 180 days
- Absence of ESRD, pancreatitis, gastroparesis, MTC, or MEN2 diagnosis in the last 730 days
- Absence of ESRD services (CPT codes from Table 9) in the last 730 days
- No concurrent GLP-1 RA-containing agent therapy
Approval and renewal
- Initial approval: 12 months
Not covered when
- ESRD (diagnosis or ESRD services CPT codes in last 730 days)
- Pancreatitis (acute or chronic, in last 730 days)
- Gastroparesis (in last 730 days)
- Medullary thyroid carcinoma (MTC) (in last 730 days)
- Multiple endocrine neoplasia syndrome type 2 (MEN2) (in last 730 days)
- Concurrent therapy with a GLP-1 RA containing agent
- Type 1 diabetes
Policy note: This is a Texas Medicaid (Texas Prior Authorization Program) policy administered by Acentra Health. Mounjaro is only eligible for patients ≥ 18 years of age (no pediatric exception unlike Trulicity/Victoza). The policy does not specify an A1C threshold for approval, only requires evidence of an HbA1c test within 180 days. The oral antidiabetic agent step therapy requirement can be bypassed if the patient has an established history of the requested medication (14 consecutive days in last 365 days). Wegovy and Zepbound appear only in Table 11 (GLP-1 RA containing agents — used to check for duplicate therapy); the document does NOT establish PA criteria for their weight loss or other in-scope indications. No quantity limits are specified in this document.
Policy effective October 31, 2025 · verified June 4, 2026 · source: GLP-1 R Apending · View policy document (PDF)