What BMI do you need for Zepbound under Delaware Medicaid?

For weight loss on Medicaid plans, Delaware Medicaid requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.

How long does a Zepbound approval last with Delaware Medicaid?

Initial approvals last 6 months, and renewals are granted in 6-month periods.

What does Delaware Medicaid require to renew Zepbound?

At least 5% weight loss from the starting weight and Adults must have lost >= 5% of baseline body weight; adolescents must have lost >= 4% of baseline body weight. If more than 50% of lost weight is regained or total weight loss from baseline is ever < 5% (adults) or < 4% (adolescents), PA may not be renewed for at least one year. Initial approval re-documentation not required at reauthorization as long as weight loss threshold is met.

How current is this information?

This page reflects Delaware Medicaid's written policy as of April 20, 2026, last verified against the source document on June 4, 2026.

Delaware Medicaid

Does Delaware Medicaid cover Zepbound?

Quick answer · Weight Loss

Delaware Medicaid covers Zepbound for weight loss with prior authorization on Medicaid.

Medicaid: Covered with requirements. BMI of 30 or higher

Last verified June 4, 2026. Policy effective April 20, 2026. Source: Pa policy. How we verify this data →

Check your card for your exact plan →

Zepbound for Weight Loss

What Delaware Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (CVD, heart_failure, CKD, hypertension, hyperlipidemia, PAD, OSA, and T2DM)
BMI at or above the 95th percentile for age and sex
Diagnosis documented with a code
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Obesity pathway (adult)

All of:

BMI >= 30 kg/m2
Adult member

Obesity pathway (pediatric)

All of:

BMI >= 95th percentile for age and weight
Pediatric member

Overweight with comorbidity (adult)

All of:

BMI >= 27 kg/m2 and < 30 kg/m2

Plus any one of:

Cardiovascular disease (CVD)
Heart failure
Chronic kidney disease stage 3a or above
Hypertension
Hyperlipidemia
Peripheral artery disease (PAD)
Moderate to severe OSA (AHI > 15 without central or mixed sleep apnea)
Type 2 diabetes

Documentation to bring

Member's relevant medical records and/or pharmacy profile
Appropriate baseline diagnostic and safety laboratory results with dates
Documentation of current weight, height, and BMI
Documentation of reduced calorie diet
Documentation of increased physical activity
If BMI is between 27-30 kg/m2: clinical co-morbid diagnosis with ICD-10 code
Confirmation that member is NOT currently on another GLP-1 agonist
Confirmation that member has no contraindicated conditions/medications with requested GLP-1
For non-preferred agent: documentation that preferred medications have been tried with results
Pharmacy claims history or pharmacy profile

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Adults must have lost >= 5% of baseline body weight; adolescents must have lost >= 4% of baseline body weight. If more than 50% of lost weight is regained or total weight loss from baseline is ever < 5% (adults) or < 4% (adolescents), PA may not be renewed for at least one year. Initial approval re-documentation not required at reauthorization as long as weight loss threshold is met. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Currently on another GLP-1 agonist
Has a contraindicated condition/disease with the requested GLP-1 agonist
Currently on a contraindicated medication with the requested GLP-1 agonist
Off-label indications without two peer-reviewed articles demonstrating safety and efficacy

Policy note: Class-level policy applies to all GLP-1 agonists. OSA as a qualifying comorbidity for the overweight pathway requires AHI > 15 without central or mixed sleep apnea (moderate to severe). Initial authorization up to 6 months in <= 30-day supplies; reauthorization 6 months in <= 90-day supplies.

Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy

Why Zepbound requests get denied by Delaware Medicaid

Based on what this policy asks for. Fix these before the first submission.

Wrong brand for the diagnosis. Zepbound and Mounjaro are the same molecule with different approved uses; a request for Zepbound under a diagnosis that matches Mounjaro is routinely denied.
Diagnosis code missing or wrong on the request.
BMI not documented in the chart notes (or documented without a baseline weight and date).
Qualifying weight-related condition not documented with its own diagnosis code.
Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Delaware Medicaid cover Zepbound?: Delaware Medicaid covers Zepbound for weight loss with prior authorization on Medicaid.
What BMI do you need for Zepbound under Delaware Medicaid?: For weight loss on Medicaid plans, Delaware Medicaid requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.
How long does a Zepbound approval last with Delaware Medicaid?: Initial approvals last 6 months, and renewals are granted in 6-month periods.
What does Delaware Medicaid require to renew Zepbound?: At least 5% weight loss from the starting weight and Adults must have lost >= 5% of baseline body weight; adolescents must have lost >= 4% of baseline body weight. If more than 50% of lost weight is regained or total weight loss from baseline is ever < 5% (adults) or < 4% (adolescents), PA may not be renewed for at least one year. Initial approval re-documentation not required at reauthorization as long as weight loss threshold is met.
How current is this information?: This page reflects Delaware Medicaid's written policy as of April 20, 2026, last verified against the source document on June 4, 2026.

Other medications under Delaware Medicaid

Zepbound coverage under other plans

All insurance plans · All medications

This page summarizes Delaware Medicaid's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.