Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Approval — OSA with PAP therapy
All of:
- Recipient is 18 years of age or older
- Established diagnosis of moderate to severe OSA with AHI ≥ 15 on polysomnography (PSG) within the previous 12 months
- Recipient does not have central or mixed sleep apnea
- Recipient does not have type 1 or type 2 diabetes
- BMI ≥ 30 kg/m2
- Prescriber attests medication will not be used concurrently with other tirzepatide products or GLP-1 receptor agonists
- Tirzepatide used as adjunct to standard of care (individualized healthy lifestyle counseling AND behavioral modification including reduced calorie diet and increased physical activity)
Plus any one of:
- Medication is prescribed concurrently with PAP therapy, unless PAP is contraindicated or causes clinically significant adverse effects
- Recipient has a history of non-adherence to PAP therapy
Continuation Approval — Weight loss ≥ 5%
All of:
- Recipient is currently receiving medication as evidenced by paid pharmacy claims
- Documentation confirms recipient met initial approval criteria and has received medication for at least 28 days
- At least 3 months follow-up documentation showing decreased AHI and improved OSA symptoms
- Tirzepatide used as adjunct to standard of care (individualized healthy lifestyle counseling AND behavioral modification)
- Request is for maintenance dose of 10mg or 15mg once weekly (if appropriate per titration schedule)
Plus any one of:
- Recipient lost ≥ 5% of baseline body weight OR maintained initial 5% weight loss with no additional weight gain
Continuation Approval — Weight loss < 5% with clinical justification (first occurrence)
All of:
- Recipient is currently receiving medication as evidenced by paid pharmacy claims
- Documentation confirms recipient met initial approval criteria and has received medication for at least 28 days
- Recipient did NOT reach weight loss goal of at least 5% AND clinical justification for continuation is provided
- At least 3 months follow-up documentation showing decreased AHI and improved OSA symptoms
- Tirzepatide used as adjunct to standard of care (individualized healthy lifestyle counseling AND behavioral modification)
- Request is for maintenance dose of 10mg or 15mg once weekly (if appropriate per titration schedule)
- Previous continuation approval was NOT for a 3-month duration (i.e., this is not a repeat <5% weight loss approval)
Documentation to bring
- Completed Louisiana Uniform Prescription Drug Prior Authorization Form
- Completed Tirzepatide (Zepbound) Treatment Agreement for Louisiana Medicaid Recipients (for initiation requests)
- Polysomnography (PSG) test results showing AHI ≥ 15, with date of test within the previous 12 months
- Documentation of most recent BMI calculation (date and result), confirming BMI ≥ 30 kg/m2
- Prescriber attestation that recipient does not have central or mixed sleep apnea
- Prescriber attestation that recipient does not have type 1 or type 2 diabetes
- Prescriber attestation regarding PAP therapy status: concurrent PAP use (unless contraindicated or causing adverse effects) OR history of non-adherence to PAP therapy
- Prescriber attestation that tirzepatide will not be used with other tirzepatide products or GLP-1 receptor agonists
- Prescriber attestation that tirzepatide will be used as adjunct to standard of care (lifestyle counseling and behavioral modification)
- For continuation: Evidence of current medication use via paid pharmacy claims
- For continuation: Documentation that recipient met initial approval criteria and has been on therapy at least 28 days
- For continuation: Baseline body weight prior to initiation of therapy and current body weight with dates
- For continuation: At least 3 months of follow-up documentation (clinical visit notes or updated test results) showing decreased AHI and OSA symptom improvement
- For continuation: Clinical justification if weight loss goal of ≥ 5% was not achieved
Approval and renewal
- Initial approval: 6 months
- Renewal: Recipient must demonstrate: (1) weight loss ≥ 5% of baseline body weight OR maintenance of initial 5% weight loss with no additional weight gain — or if <5% weight loss, clinical justification must be provided; AND (2) at least 3 months follow-up documentation (clinic notes or updated test results) showing decreased AHI and improved OSA symptoms. Continuation approval duration: 12 months if weight loss >5%; 3 months if weight loss <5% with clinical justification (if previously approved for 3 months with <5% weight loss, do not approve again). Diabetes exclusion and BMI requirement are not re-verified at continuation; however, lifestyle program adherence is re-affirmed. Maintenance dose of 10mg or 15mg once weekly is required for continuation (if appropriate per titration schedule).
- Renewal: At least 4 weeks on therapy before the first renewal.
- Renewal: Staying on a maintenance dose of at least 10 mg.
Not covered when
- Type 2 diabetes (both T1DM and T2DM are excluded for this indication)
- Central or mixed sleep apnea
- Concurrent use with other tirzepatide products
- Concurrent use with any GLP-1 receptor agonists
- Type 1 diabetes
Policy note: This is a Louisiana Medicaid policy effective January 2026 (policy created June 2025). The OSA must be moderate to severe (AHI ≥ 15). PAP therapy is required concurrently unless contraindicated, clinically adverse, or if recipient has a documented history of PAP non-adherence — these are presented as two alternative qualifying conditions, not a strict step-therapy requirement. The policy explicitly excludes both T1DM and T2DM patients from this indication. Continuation approval duration is variable: 12 months for ≥ 5% weight loss; 3 months for < 5% with clinical justification; no approval if previously approved for 3 months and < 5% weight loss is again the result. Maintenance dose of 10mg or 15mg required at continuation.
Policy effective January 1, 2026 · verified June 2, 2026 · source: Zepbound.06052025 · View policy document (PDF)