Oregon Health Plan does not cover Wegovy or Zepbound for weight loss

The Oregon Health Plan does not cover Wegovy, Zepbound, Foundayo, Saxenda or other drugs for adults when they are prescribed only for weight loss. Members eligible for EPSDT review can be approved case by case, and adults can get Wegovy or Zepbound with prior authorization only for another listed condition: established cardiovascular disease or MASH for Wegovy, moderate to severe sleep apnea with obesity for Zepbound.12346

Every drug used for weight management needs prior authorization under the Oregon Health Plan's weight management criteria. Adults are approved only for a listed non-weight-loss condition; members eligible for EPSDT review are reviewed case by case. First approvals last up to 6 months and renewals up to 12 months.1245

• Except for MASH requests: a BMI of 30 or more, or 25 or more with a comorbid condition (such as diabetes, high blood pressure, dyslipidemia, fatty liver disease or cardiovascular disease), or at or above the 95th percentile for age and sex for adolescents.
• Except for MASH requests: the patient will take part in a weight management lifestyle program along with the drug.
• Adults: the request must meet a listed indication other than weight loss: Wegovy injection or tablets for established cardiovascular disease (such as a past heart attack, stroke or symptomatic peripheral arterial disease), Wegovy injection or liraglutide for MASH with stage 2 or 3 fibrosis, or Zepbound for moderate to severe obstructive sleep apnea with a BMI of 30 or more. Cardiovascular and sleep apnea requests also need at least 3 months of a provider-led weight loss plan in the past 6 months.
• Patients without a type 2 diabetes diagnosis must have been screened for diabetes in the past year with results showing they do not have it (for example, A1C under 6.5%).
• MASH requests also need a liver biopsy or noninvasive testing showing stage 2 or 3 fibrosis in the past 24 months, and the drug ordered by or with a hepatologist or gastroenterologist.
• Renewal for adults with cardiovascular disease or sleep apnea: a BMI reduction of at least 5% lost or kept, adherence, and continued participation in a weight loss treatment plan.

Coverage for other uses the FDA has approved:

• Wegovy (injection), established cardiovascular disease (past heart attack, stroke or symptomatic peripheral arterial disease), injection or tablets: Covered with prior authorization1910
• Wegovy (injection), MASH with stage 2 or 3 liver fibrosis in adults (injection only): Covered with prior authorization112
• Zepbound, moderate to severe obstructive sleep apnea in adults with obesity (BMI of 30 or more): Covered with prior authorization211

What changed, and when:

CMS BALANCE model: CMS's BALANCE model page names no participating states, and we found no Oregon Health Authority announcement that Oregon has joined.13

The 2026 PEBB Statewide and Choice member handbooks, administered by Providence Health Plan, list drugs used for weight loss among the prescription drug exclusions. For 2027, PEBB moves to Moda Health and Kaiser Permanente plans, with Judi Rx handling prescription drugs for the Moda plans.141516

Pharmacy benefit: Providence Health Plan (Statewide and Choice plans) for 2026; Judi Rx for the Moda Health plans from 2027.

Marketplace (ACA) plans: Oregon's essential health benefits benchmark plan excludes obesity and weight control treatment, along with other services and supplies for weight loss, and lists weight loss programs as not covered.19

On the Oregon Health Plan fee-for-service preferred drug list, Trulicity, Victoza, generic liraglutide, Byetta and exenatide are preferred GLP-1 diabetes drugs, while Ozempic, Rybelsus, Mounjaro and Bydureon BCise are non-preferred. Preferred drugs need no prior authorization as second-line therapy with metformin; a non-preferred drug needs a type 2 diabetes diagnosis and a metformin trial or a reason metformin cannot be used.78

In 2025, Oregon Health Plan paid for 63,577 GLP-1 prescriptions, $63.3 million before rebates: 15 per 1,000 residents, against 32 across the states and DC, 39th of 51.69 It reimbursed 7 GLP-1 products that year. Every state, ranked.

CMS hides counts under 11 in a quarter, so 62 rows count as zero here and the totals are a floor.

Part D still excludes drugs used for weight loss alone: the Part D drug definition excludes drugs and uses Medicaid may exclude under SSA §1927(d)(2), which lists agents used for weight loss. Part D plans can cover GLP-1s for type 2 diabetes, MACE risk reduction (Wegovy), moderate-to-severe obstructive sleep apnea (Zepbound) and noncirrhotic MASH with fibrosis (Wegovy). For weight loss alone, the Medicare GLP-1 Bridge demonstration (July 1, 2026 – Dec 31, 2027) gives eligible Part D enrollees Foundayo, Wegovy or Zepbound KwikPen for a $50 monthly copay, outside the Part D benefit. The BALANCE Model's Part D component is not launching in 2027.4445353631392434

• Medicare GLP-1 Bridge (demonstration) (active, from 2026-07-01): Runs July 1, 2026 to December 31, 2027 (extended). Outside the Part D benefit: $50 copay per one-month supply (28 or 30 days), Part D deductible does not apply, the copay does not count toward TrOOP, no low-income subsidy. Covers Foundayo, Wegovy (injection or tablet) and Zepbound KwikPen only (not Zepbound single-dose vials or pens). Eligibility: age 18+ and, when starting GLP-1 therapy, BMI ≥35; or BMI ≥30 with heart failure with preserved ejection fraction, uncontrolled hypertension, or CKD stage 3a+; or BMI ≥27 with prediabetes, prior heart attack or stroke, or symptomatic peripheral artery disease. People with type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease are not eligible (their Part D plan may cover GLP-1s for those conditions). Prior authorization required; valid through Dec 31, 2027 unless the patient changes GLP-1s.3132332439404142433837
• BALANCE Model — Medicare Part D component (not launching in 2027; future implementation described by CMS only as 'potential'): Originally announced to launch in Part D in January 2027. CMS's BALANCE page FAQ now refers to 'the BALANCE Model not launching in Medicare in 2027' and extends the Bridge through Dec 31, 2027 to collect data 'ahead of potential implementation of BALANCE in Part D'. No new start date is published.262824

In 2024, Medicare Part D drug plans paid for 203,289 GLP-1 claims from prescribers in Oregon, $248.0 million in total drug cost.70

The lowest price among the programs that ship to every state is WellMedr: $492 for 12 months ($41 a month); $99 month to month, fees in.74 Includes a sale seen on November 5, 2026; the price returns to the standing price when it ends. The cheapest programs, ranked, or every program, ranked on our score.

Prices are what each program charged at its own checkout, fees in, with the total due for the plan length first. Compounded GLP-1s are prepared by a pharmacy to a prescription, and they are not FDA-approved; the section on compounding explains what that means.

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29 more programs we rank ship to fewer than 50 states, or don’t say how many. We don’t record which states they leave out, so check Oregon on their sites: Embody, Collective, SnagRx, Enhanced, Direct Meds, Gala Health, GobyMeds, CoreAge Rx, Maximus Tribe, Brightmeds, SkinnyRx, Willow, Strut Health, Enhance MD, LumiMeds, VivioMD, MEDGm, MyDrHank, Zevay, LevelsRx, Hume Care, ReadyRx, Hers, Luvo Health, Remedy Meds, Hims, DudeMeds, G-Plans and Found.

The makers also sell some brand-name GLP-1s for cash, at the same price in every state, with a prescription:

These are standing prices. The Zepbound and Wegovy rankings list each dose and the terms of each offer.

Compounded GLP-1s are prepared by a pharmacy to a prescription. They are not FDA-approved: the FDA doesn’t review their safety, effectiveness or quality before they’re sold, and they are not the same as Wegovy or Zepbound. Formulas can differ from one pharmacy to the next, and some add ingredients such as vitamin B12.7576 Compounding pharmacies are licensed and inspected by state boards of pharmacy; outsourcing facilities (503B) also register with the FDA and are inspected by it. The FDA can issue warning letters when either breaks rules on safety or sterility.

The FDA’s register lists 0 outsourcing facilities (503B) in Oregon, as of November 6, 2026.71