Louisiana Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
6 months of a documented diet and exercise program
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.

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
To renew, the plan looks for at least 5% weight loss from the starting weight, 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), at least 4 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 10 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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.pdf