Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (T2DM, dyslipidemia, HTN, CVD, NAFLD/NASH, PCOS, OSA, asthma, osteoarthritis, urinary stress incontinence, GERD, cancer, depression, psychotic disorders, metabolic syndrome, prediabetes, female infertility, and male hypogonadism)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult Weight Management
All of:
- Age >= 18 years
- Prescriber provides baseline weight and BMI
- Treatment plan includes comprehensive adjunct lifestyle interventions (diet modification, physical activity, behavioral therapy)
- Patient able to titrate and maintain therapeutic dose per FDA-approved labeling
- Dose does not exceed 15 mg SC once weekly
Plus any one of:
- BMI >= 30 kg/m2
- BMI >= 27 kg/m2 AND at least one weight-related comorbidity (Table 2)
Documentation to bring
- Baseline weight and BMI documentation
- Documentation of comprehensive adjunct lifestyle intervention plan (diet, physical activity, behavioral therapy)
- Documentation confirming patient meets BMI threshold (>=30 kg/m2, or >=27 kg/m2 with comorbidity)
- Documentation of qualifying weight-related comorbidity if using BMI >=27 pathway
- Claims history or supporting documentation of prior medication use if applicable
Quantity limits
- 15 mg — Per FDA-approved dosing; dose not to exceed 15 mg SC once weekly
Approval and renewal
- 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 pretreatment weight at 12 weeks (maintained) OR 10% of pretreatment weight at 28 weeks (maintained). NOTE: Zepbound is listed in Table 4 as a high-cost agent with specific weight loss thresholds (6% at 8 weeks initial, 13% at subsequent renewals, 20% at >=52 weeks); however, Table 4 additional general criteria do NOT apply to Zepbound as of 4/1/2024. The applicable renewal threshold reverts to the general non-Table-4 criteria: 5% at 12 weeks or 10% at 28 weeks. First renewal approval: 6 months; subsequent renewals: 12 months. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Professional samples may not be used to establish patient history of medication usage
- Zepbound is listed in Table 4 (high-cost agent) but the Additional General Criteria for Table 4 do NOT apply as of 4/1/2024; however, previous failures to Table 4 agents with a minimum 1-year waiting period rule and switching rationale requirements may still be reviewed
- Patients with T2DM must use the formulation indicated for T2DM (Table 4 additional criteria; note Zepbound is exempt from Table 4 as of 4/1/2024 but T2DM formulation guidance may still apply)
Policy note: This is a Kansas Medicaid (KMAP) PA policy. Zepbound is exempt from the 'Additional General Criteria' (Table 4 high-cost agent requirements, including severe obesity BMI >=40 threshold and 3-month lifestyle modification requirement) as of 4/1/2024. Zepbound is FDA-approved for adults only (age >=18); no pediatric indication listed. Initial approval duration is 28 weeks (as of 4/1/2024). Table 4 lists Zepbound with 6%/13%/20% weight loss thresholds, but the note explicitly states the Additional General Criteria do not apply to Zepbound as of 4/1/2024, so the standard non-Table-4 renewal criteria (5% at 12 weeks or 10% at 28 weeks) apply. Preferred PDL drug must be used unless non-preferred PDL PA criteria are met. The OSA indication for Zepbound is not addressed in this document; only weight management is covered here.
Policy effective August 14, 2024 · verified June 4, 2026 · source: Anti-Obesity-Medications-PDF