Indiana Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
A1C no higher than 6.5%
Prescribed by or in consultation with a specialist
Diagnosed obstructive sleep apnea (AHI of 15 or higher)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Moderate-to-Severe OSA with Obesity — Current AHI >=15

All of:

Member is 18 years of age or older
Diagnosis of moderate to severe OSA (AHI >=15 events/hour) in individuals with obesity
Documented BMI >= 30 kg/m2 with baseline weight before initiating Zepbound (chart documentation within past 3 months)
AHI >=15 events/hour on PSG or HSAT reviewed and interpreted by sleep medicine-certified physician (documentation from study obtained within past year)
Member does not have Type 1 or Type 2 diabetes mellitus
HbA1c < 6.5% (chart documentation within past 3 months)
No diagnosis of central or mixed sleep apnea with >=50% mixed/central apneas/hypopneas (prescriber attestation)
Member will use in combination with reduced calorie diet and increased physical activity
No concurrent use with another GLP-1 RA or combination product (including tirzepatide-containing products)
Dose does not exceed 15 mg/week

Moderate-to-Severe OSA with Obesity — Prior AHI >=15 on PAP Therapy

All of:

Member is 18 years of age or older
Diagnosis of moderate to severe OSA (AHI >=15 events/hour) in individuals with obesity
Documented BMI >= 30 kg/m2 with baseline weight before initiating Zepbound (chart documentation within past 3 months)
Prior AHI >=15 events/hour on PSG or HSAT reviewed and interpreted by sleep medicine-certified physician (documentation required)
Member does not have Type 1 or Type 2 diabetes mellitus
HbA1c < 6.5% (chart documentation within past 3 months)
No diagnosis of central or mixed sleep apnea with >=50% mixed/central apneas/hypopneas (prescriber attestation)
Member will use in combination with reduced calorie diet and increased physical activity
No concurrent use with another GLP-1 RA or combination product (including tirzepatide-containing products)
Dose does not exceed 15 mg/week

Plus any one of:

Currently utilizing PAP therapy (CPAP or BiPAP) with documented adherence within past 90 days (>=4 hours/night for >=70% of nights in a 30-day period, supported by PAP therapy report or chart note)
Prescriber has provided valid medical justification why member cannot use PAP therapy (e.g., intellectual disabilities)

Documentation to bring

Chart documentation confirming BMI >= 30 kg/m2 and baseline weight obtained within past 3 months
PSG or HSAT report with AHI >=15 events/hour reviewed and interpreted by sleep medicine-certified physician (obtained within past year), OR prior PSG/HSAT report with AHI >=15 plus PAP therapy adherence documentation or medical justification for PAP inability
HbA1c lab result < 6.5% obtained within past 3 months
Prescriber attestation of no T1D or T2D diagnosis
Prescriber attestation of no central or mixed sleep apnea (>=50% mixed/central apneas/hypopneas)
PAP therapy adherence report (within past 90 days showing >=4 hours/night for >=70% of nights in 30-day period) if using the PAP pathway, OR prescriber medical justification for PAP inability
Prescriber attestation of diet/physical activity use
Prescriber attestation of no concurrent GLP-1 RA or tirzepatide-containing products

Quantity limits

all strengths — max 15 mg/week

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 5% weight loss from the starting weight, At first reauthorization (therapy >1 year and <2 years): documented reduction in AHI from baseline (PSG, HSAT, or CPAP/BiPAP sleep data obtained within past 3 months). At all reauthorizations: documented meaningful weight loss of at least 5% from baseline, prescriber attests no T1D or T2D, prescriber attests no central or mixed sleep apnea diagnosis, no concurrent GLP-1 RA or tirzepatide-containing products, dose does not exceed 15 mg/week, history of requested agent at least 84 days within past 112 days, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Type 2 diabetes excluded
HbA1c >=6.5% excluded
Central or mixed sleep apnea with >=50% mixed/central apneas/hypopneas excluded
No concurrent use with another GLP-1 RA or combination product including tirzepatide-containing products
Dose must not exceed 15 mg/week
Weight loss as the sole indication is explicitly not covered
Type 1 diabetes

Policy note: Document states 'ZEPBOUND (TIRZEPATIDE) (NOT COVERED EXCLUSIVELY FOR WEIGHT LOSS).' OSA-only indication: members must NOT have T1D or T2D and must have HbA1c <6.5%. Two pathways: (1) current PSG/HSAT with AHI >=15 within past year; (2) prior PSG/HSAT with AHI >=15 and current PAP therapy adherence or medical justification for PAP non-use. PAP adherence defined as >=4 hours/night for >=70% of nights within a 30-day period. At first renewal only (therapy 1-2 years), AHI reduction from baseline must be documented. At ALL renewals, >=5% weight loss from baseline required. Specialist required: sleep medicine-certified physician must review and interpret the diagnostic sleep study.

Policy effective July 1, 2026 · verified June 4, 2026 · source: 20260701_Public-Facing_GLP-1%20RA-GIP-Combinations_PA_Final.pdf