Kansas Medicaid coverage for Zepbound (Weight Loss)

Medicaid

Covered with requirements

What 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