The facts
Weight loss
Generally no
Type 2 diabetes
Yes, with step therapy
Prior auth
Step therapy required
Typical cost
Plan-specific
The criteria, as published
5 of 9 criteria are stated in the Molina Healthcare 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
Tier 3 with step therapy on the 2026 Utah formulary
“*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/3ML (Semaglutide) Tier 3 ST; QL (3 ML per 25 days)”
molinamarketplace.com · 2026-04-01- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Ozempic.
- Qualifying conditions
Diabetes required for diabetes drugs (California 2026 Agreement)
“Weight loss drugs, unless approved by Medical Necessity for morbid obesity (Class III Obesity). Only individuals with diabetes are eligible to receive coverage of applicable drugs indicated for the treatment of diabetes.”
molinamarketplace.com · 2026 plan year- 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
Yes: step therapy required
“ST Step Therapy is required. If we have paid for you to have the required Step Therapy drug(s) in the past, this drug will be paid for at the pharmacy without need for a Prior Authorization or Step Therapy exception request.”
molinamarketplace.com · 2026-04-01- Quantity limit
3 mL per 25 days (0.25/0.5 mg and 1 mg pens)
“*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/3ML (Semaglutide) Tier 3 ST; QL (3 ML per 25 days)”
molinamarketplace.com · 2026-04-01- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
Yes: weight loss drugs are listed as non-covered
“Weight loss drugs, unless approved by Medical Necessity for morbid obesity (Class III Obesity). Only individuals with diabetes are eligible to receive coverage of applicable drugs indicated for the treatment of diabetes.”
molinamarketplace.com · 2026 plan year- 2026 change
- Not published in what we readAsk whether Ozempic'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 · CVS Caremark
Molina Healthcare hands its formulary to CVS Caremark, so what is preferred, excluded or subject to step therapy is CVS Caremark’s decision rather than Molina Healthcare’s. When you read that a formulary changed, this is the company that changed it.
- 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 Molina Healthcare 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: weight loss drugs are listed as non-covered.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Ozempic, 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. Conditions: Diabetes required for diabetes drugs (California 2026 Agreement). Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
What the documents say: Yes: step therapy required. If you already tried that drug, or cannot take it, the request should say so with dates.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. 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
Ask your doctor which step drug Molina requires first, or have them file a step therapy exception if you already tried it. Molina's pharmacy claims run through CVS Caremark, so CVS Caremark can confirm formulary status and rejected claims.
Coverage is plan-specific: this page reports what Molina Healthcare publishes, not a promise about your plan. Not medical or insurance advice.
