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Centene

Does Centene cover Zepbound?

No. Centene's policies on file exclude Zepbound for weight loss on ACA Marketplace plans.

Policy document

  • ACA Marketplace: Not covered. Use of Zepbound for the treatment of weight management is a benefit exclusion and will not be authorized.

Earliest policy review June 2, 2026. How we verify · Check your exact plan

Full requirements: Zepbound for Weight Loss (1 plan type)

Applies to ACA Marketplace plans.

Not covered

Use of Zepbound for the treatment of weight management is a benefit exclusion and will not be authorized.

Policy note: The policy explicitly states that use of Zepbound for weight management is a benefit exclusion and will not be authorized, for both initial approval and continued therapy. This applies to HIM/ICHRA and Medicaid lines of business.

Policy effective December 20, 2024 · verified June 2, 2026 · source: Cp.Pmn.298 · View policy document (PDF)

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Full requirements: Zepbound for Obstructive Sleep Apnea (OSA) (1 plan type)

Applies to ACA Marketplace plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Initial Approval – OSA (without concurrent T2DM)

All of:

  • Diagnosis of moderate to severe OSA confirmed by polysomnography or home sleep apnea test within past 12 months with AHI ≥ 15 respiratory events per hour
  • Age ≥ 18 years
  • BMI ≥ 30 kg/m2
  • Member does not have central or mixed sleep apnea
  • Active enrollment in physician-directed weight loss program for at least 6 months involving reduced calorie diet, increased physical activity, and behavioral modification, with plan to continue enrollment while on Zepbound
  • Zepbound not prescribed concurrently with other tirzepatide-containing products or any other GLP-1 receptor agonist
  • Documentation of member's baseline body weight in kg
  • Dose does not exceed escalation schedule (2.5mg wk1-4, 5mg wk5-8, 7.5mg wk9-12, 10mg wk13-16, 12.5mg wk17-20, 15mg wk21-24) and quantity limit (1 pen/vial per week for single-dose or 1 vial/KwikPen every 4 weeks for multi-dose)

Plus any one of:

  • Member has continued symptoms of OSA despite adherence to PAP therapy (≥4 hours/night for ≥70% of nights)
  • Member is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)

Initial Approval – OSA with concurrent T2DM (Illinois HIM: step therapy waived as of 1/1/2026)

All of:

  • Diagnosis of moderate to severe OSA confirmed by polysomnography or home sleep apnea test within past 12 months with AHI ≥ 15 respiratory events per hour
  • Age ≥ 18 years
  • BMI ≥ 30 kg/m2
  • Member does not have central or mixed sleep apnea
  • Concurrent diagnosis of type 2 diabetes mellitus
  • Member has received optimal diabetic standard of care therapy as evidenced by a trial of ≥ 3 consecutive months each of ALL of: (1) Ozempic or Rybelsus, (2) Trulicity, and (3) liraglutide (generic Victoza), unless clinically significant adverse effects are experienced or all are contraindicated
  • If member is currently on a GLP-1 receptor agonist and requesting switch to Zepbound, medical justification supports necessity (intolerance due to common GI adverse effects is NOT acceptable justification)
  • Active enrollment in physician-directed weight loss program for at least 6 months involving reduced calorie diet, increased physical activity, and behavioral modification, with plan to continue enrollment while on Zepbound
  • Zepbound not prescribed concurrently with other tirzepatide-containing products or any other GLP-1 receptor agonist
  • Documentation of member's baseline body weight in kg
  • Dose does not exceed escalation schedule and quantity limit

Plus any one of:

  • Member has continued symptoms of OSA despite adherence to PAP therapy (≥4 hours/night for ≥70% of nights)
  • Member is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)

Documentation to bring

  • Polysomnography or home sleep apnea test result within the past 12 months confirming AHI ≥ 15 respiratory events per hour
  • Documentation confirming absence of central or mixed sleep apnea
  • Documentation of member's baseline body weight in kg
  • Documentation of active enrollment in physician-directed weight loss program for at least 6 months (reduced calorie diet, increased physical activity, behavioral modification)
  • Documentation of continued enrollment in physician-directed weight loss program while on Zepbound
  • Documentation of PAP therapy adherence failure (≥4 hours/night for ≥70% of nights with continued OSA symptoms) OR documentation that member is not a candidate for PAP therapy
  • For members with concurrent T2DM: Documentation of ≥ 3 consecutive months trial of each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) unless clinically significant adverse effects or contraindication documented (note: Illinois HIM waived as of 1/1/2026)
  • For members currently on a GLP-1 switching to Zepbound: Medical justification for the switch (GI intolerance to GLP-1 class is not acceptable)

Quantity limits

  • 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — Single-dose formulation: 4 pens or vials (1 per week); Multi-dose formulation: 1 vial or KwikPen every 4 weeks; Single-dose formulation: 12 pens or vials; Multi-dose formulation: 3 vials or KwikPens (84-day)

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: First renewal: member must have lost ≥5% of baseline body weight AND show at least one of: AHI reduction from baseline, improvement in SASHB score, or improvement in sleep-related patient-reported outcomes (ESS, Calgary SAQLI, FOSQ, or PROMIS). Second and subsequent renewals: member must have lost weight and/or maintained weight loss AND show stabilization or improvement in AHI, SASHB, or sleep-related patient-reported outcomes. Maintenance dose must be ≥10 mg once weekly after initial dose escalation. Continued enrollment in physician-directed weight loss program required. Step therapy (prior GLP-1 trial for T2DM comorbidity) is NOT re-verified at continuation. First reauthorization: 6 months; subsequent reauthorizations: 12 months.
  • Renewal: Staying on a maintenance dose of at least 10 mg.

Not covered when

  • Central or mixed sleep apnea
  • Concurrent use with other tirzepatide-containing products
  • Concurrent use with any other GLP-1 receptor agonist
  • Personal or family history of medullary thyroid carcinoma (MTC) — contraindication
  • Multiple endocrine neoplasia syndrome type 2 (MEN 2) — contraindication
  • Known serious hypersensitivity to tirzepatide or any excipients in Zepbound — contraindication

Exceptions

  • Illinois_HIM: Step therapy requirements (prior GLP-1 trials for T2DM comorbidity and PAP therapy trial) do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: Policy applies to HIM/ICHRA and Medicaid lines of business. OSA must be moderate to severe (AHI ≥ 15). The prior GLP-1 step therapy requirement (Ozempic/Rybelsus, Trulicity, liraglutide) applies ONLY to members with concurrent T2DM. PAP therapy must have been attempted and failed (with adherence defined as ≥4 hours/night ≥70% of nights) or member must not be a candidate for PAP. Continuation requires maintenance dose ≥10 mg weekly after dose escalation. First reauthorization approval: 6 months; subsequent reauthorizations: 12 months. Multi-dose vials and KwikPens are available in 10, 20, 30, 40, 50, 60 mg/2.4 mL concentrations corresponding to four doses per vial/pen.

Policy effective December 20, 2024 · verified June 2, 2026 · source: Cp.Pmn.298 · View policy document (PDF)

Open on its own page →

If weight loss isn't covered on your plan

Centene has separate Zepbound policies that don't depend on that benefit:

Questions people ask
Does Centene cover Zepbound?
No. Centene's policies on file exclude Zepbound for weight loss on ACA Marketplace plans.
How long does a Zepbound approval last with Centene?
Obstructive Sleep Apnea (OSA) — Applies to ACA Marketplace plans. Initial approval: 6 months. Renewal: every 6 months.
What does Centene require to renew Zepbound?
Obstructive Sleep Apnea (OSA) — Applies to ACA Marketplace plans. First renewal: member must have lost ≥5% of baseline body weight AND show at least one of: AHI reduction from baseline, improvement in SASHB score, or improvement in sleep-related patient-reported outcomes (ESS, Calgary SAQLI, FOSQ, or PROMIS). Second and subsequent renewals: member must have lost weight and/or maintained weight loss AND show stabilization or improvement in AHI, SASHB, or sleep-related patient-reported outcomes. Maintenance dose must be ≥10 mg once weekly after initial dose escalation. Continued enrollment in physician-directed weight loss program required. Step therapy (prior GLP-1 trial for T2DM comorbidity) is NOT re-verified at continuation. First reauthorization: 6 months; subsequent reauthorizations: 12 months. Staying on a maintenance dose of at least 10 mg.
How current is this information?
The oldest review date among the policies on this page is June 2, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Centene: Mounjaro, Ozempic, Wegovy

Zepbound under other plans: Aetna, Cigna, Medicare GLP-1 Bridge (CMS), UnitedHealthcare, Alabama Medicaid, BCBS Alabama, BCBS Arizona, BCBS Arkansas

All insurance plans · All medications

Summary of Centene's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.