The facts
Weight loss
Excluded
Type 2 diabetes
Not indicated
Prior auth
Not verified
Typical cost
Plan-specific
The criteria, as published
2 of 9 criteria are stated in the Ambetter (Centene) documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Not on the 2026 Texas or Florida formulary (non-formulary)
“Non-Formulary Drugs – Drugs not found on this formulary are considered nonformulary drugs. To obtain non-formulary drugs your provider would have to submit a regular Prior Authorization request.”
ambetterhealth.com · 2026 plan year (updated October 2026)- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Wegovy.
- Qualifying conditions
- Not published in what we readAsk which conditions the Wegovy criteria accept alongside BMI.
- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
- Not published in what we readAsk whether another drug has to be tried before Wegovy.
- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
Yes: non-formulary weight loss drugs are a benefit excluded use
“2. Request is not for a benefit excluded use (e.g., cosmetic, non-formulary weight loss drugs);”
ambetterhealth.com · 2025-11 (last review)- 2026 change
- Not published in what we readAsk whether Wegovy's status changed this year or changes at your next renewal.
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
- 3
Your state or region
These plans are sold state by state, each with its own drug list, so the answer for one state does not carry to the next. Check the formulary for your state and plan year.
How prior authorization works here
Six steps. Specifics come from the criteria above; where Ambetter (Centene) does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask whether your plan includes the weight-loss drug benefit. On whether a plan can leave it out, the documents say: Yes: non-formulary weight loss drugs are a benefit excluded use.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Wegovy, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Any weight-related conditions, with diagnosis codes. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
Ask whether another drug must come first. If you have already tried one, the request should list it with dates and the reason it stopped.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Our Wegovy prior authorization letter template covers the cover letter. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
Ask how long the approval lasts and what the renewal needs, so the gap does not catch you out.
Get your real answer
Log in at AmbetterHealth.com, open your state's 2026 formulary or the Drug Cost tool, and search the drug by name. If it is not listed, ask your doctor whether a non-formulary request is worth filing, knowing Centene's policy treats non-formulary weight loss drugs as a benefit exclusion.
Coverage is plan-specific: this page reports what Ambetter (Centene) publishes, not a promise about your plan. Not medical or insurance advice.
