Kentucky Medicaid coverage for Zepbound (Osa)

What you need to qualify

• Age 18 and older
• BMI of 30 or higher
• Prescribed by or in consultation with a specialist
• Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Progress notes documenting confirmed diagnosis of moderate to severe OSA
• AHI/RDI/REI value confirming >= 15 events/hour (predominantly obstructive) OR >= 5 events/hour with at least one typical OSA symptom
• Documentation of BMI >= 30 kg/m2
• Documentation of patient's baseline weight
• Confirmation that prescriber is or has consulted with a neurologist, sleep specialist, or other OSA specialist
• Documentation of >= 3-month trial with failure, contraindication, or intolerance of APAP, BiPAP, or CPAP
• Prescriber attestation that medication will be used with reduced calorie diet and increased physical activity
• Documentation confirming no history of diabetes
• Current A1C result confirming < 6.5%
• Confirmation of no personal or family history of MTC or MEN 2
• For renewal: AHI/RDI/REI result showing >= 15 events/hour reduction or >= 50% reduction
• For renewal: Documentation of >= 5% reduction in baseline body weight OR documentation assessing lifestyle and diet interventions if weight loss goal not met

Quantity limits

• all strengths — 4 pens (2 mL) per 28 days

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 Renewal requires: (1) reduction in AHI/RDI/REI by >=15 events/hour OR >=50%; AND (2) at least 5% reduction in baseline body weight OR documentation assessing lifestyle and diet interventions if weight loss goal not met. Diabetes exclusion (history of diabetes or A1C >=6.5%) is re-verified at renewal. PAP trial requirement is NOT re-checked at renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• History of diabetes (any type)
• Current A1C >= 6.5%
• Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Concomitant use of another GLP-1 or dual GLP-1/GIP receptor agonist

Policy note: This policy is for the OSA indication only. The document excludes patients with a history of diabetes OR current A1C >= 6.5%, making this a non-diabetic OSA population only. PAP device trial (APAP, BiPAP, or CPAP) for >= 3 months with failure, contraindication, or intolerance is required before approval. The AHI lower threshold pathway (AHI >= 5) requires at least one typical OSA symptom. At renewal, the AHI improvement threshold (>=15 events/hour OR >=50% reduction) must be documented. Weight loss of >= 5% from baseline is the renewal weight threshold, but if not met, documentation of lifestyle/diet interventions is an acceptable alternative. Managed by MedImpact Healthcare Systems on behalf of Kentucky Medicaid. Copyright 2025 MedImpact Healthcare Systems, Inc.

verified June 4, 2026 · source: zepbound_pa_criteria.pdf