Connecticut Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
Diagnosis documented with a code (G4733)
6 months of a documented diet and exercise program
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

Qualification pathways

You can qualify through any one of these.

Initial and Annual Authorization for OSA

All of:

Established diagnosis of obstructive sleep apnea (OSA) with AHI >= 15
Member is 18 years of age or older
Currently using AND will continue to use positive airway pressure (PAP) treatment, unless a contraindication to PAP exists
Active participation in comprehensive adjunct lifestyle interventions (diet modifications, physical activity, nutritional counseling, and/or behavioral therapy)
Diagnosis code G4733 submitted on pharmacy claim in Field 424-DO
Prescriber completes and submits the Zepbound for Treatment of Obstructive Sleep Apnea PA form with all required information

Documentation to bring

Completed Zepbound for Treatment of Obstructive Sleep Apnea Prior Authorization Form (available at www.ctdssmap.com under Pharmacy Information tab)
Documentation of established OSA diagnosis including AHI >= 15
Documentation of current PAP therapy use (or documented contraindication to PAP)
Documentation of active participation in comprehensive adjunct lifestyle interventions (diet, physical activity, nutritional counseling, and/or behavioral therapy)
Diagnosis code G4733 submitted on pharmacy claim in Field 424-DO

Approval and renewal

Renewal: every 12 months

Policy note: PA is required at initiation of new therapy and annually thereafter. Reimbursed through the pharmacy benefit only. Dispensed under HUSKY Health Programs A, B, C, and D. PAP therapy is required unless a contraindication exists (not a prior-trial requirement — concurrent use is mandated). The bulletin does not specify quantity limits or initial approval duration; annual renewal is explicitly stated. Document does not address weight_loss indication for Zepbound.

Policy effective July 1, 2025 · verified June 3, 2026 · source: Get-Download-File