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Zepbound Clinical Prior Authorization Criteria Guide Updates

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The Vendor Drug Program (VDP) has updated the Zepbound (tirzapetide) clinical criteria guide. The following changes will go into effect on November 24, 2025:

  • New Zepbound generic code numbers were added to the “Drugs Requiring Prior Authorization” table:
    • 56686 for Zepbound 12.5 mg/0.5 ml vial
    • 56687 for Zepbound 15 mg/0.5 ml vial
  • The clinical prior authorization criteria that are related to the contraindicated diagnosis check were updated. VDP removed the diagnosis of gastroparesis and changed the look-back period for the following diagnoses to 730 days (or about two years):
    • Medullary thyroid carcinoma
    • Multiple endocrine neoplasia syndrome type 2

Texas Medicaid and managed care organizations (MCOs) will implement the updated clinical prior authorization requirements for Zepbound on November 24, 2025.

Email vdp-formulary@hhsc.state.tx.us with comments or any questions.