Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Adult (≥ 18 years): BMI ≥ 35 kg/m2 (no comorbidity required)
All of:
- Appropriate diagnosis
- Member is ≥ 18 years of age
- Member weight documented within 90 days prior to initiation of pharmacotherapy for obesity
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested quantity ≤ 4 pens/28 days
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Member BMI is ≥ 35 kg/m2 (within 90 days prior to initiation)
Adult (≥ 18 years): BMI ≥ 30 kg/m2 with specific high-severity comorbidity
All of:
- Appropriate diagnosis
- Member is ≥ 18 years of age
- Member weight documented within 90 days prior to initiation of pharmacotherapy for obesity
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested quantity ≤ 4 pens/28 days
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Member BMI is ≥ 30 kg/m2 (within 90 days prior to initiation)
Plus any one of:
- Heart failure with preserved ejection fraction
- Uncontrolled hypertension (systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite concurrent treatment with two antihypertensive medications)
- Chronic kidney disease stage 3a or above
- Moderate or severe obstructive sleep apnea (AHI > 15 without central or mixed sleep apnea)
Adult (≥ 18 years): BMI ≥ 27 kg/m2 with qualifying comorbidity
All of:
- Appropriate diagnosis
- Member is ≥ 18 years of age
- Member weight documented within 90 days prior to initiation of pharmacotherapy for obesity
- Member has been counseled to continue reduced-calorie diet and increased physical activity
- Requested quantity ≤ 4 pens/28 days
- Requested agent will not be used in combination with another GLP-1 receptor agonist
- Member BMI is ≥ 27 kg/m2 (within 90 days prior to initiation)
Plus any one of:
- Pre-diabetes (A1C ≥ 5.7% and < 6.5%) and member is not a candidate for an anti-diabetic GLP-1 agent
- History of myocardial infarction
- History of stroke
- Noncirrhotic MASH with moderate to advanced liver fibrosis (stages F2 to F3)
- Symptomatic peripheral artery disease
- Type 2 diabetes mellitus
Documentation to bring
- Documentation of appropriate diagnosis
- Documentation that member is ≥ 18 years of age
- Member weight dated within 90 days prior to initiation of pharmacotherapy for obesity
- BMI documentation: ≥ 35 kg/m2 (no comorbidity); ≥ 30 kg/m2 with high-severity comorbidity; or ≥ 27 kg/m2 with qualifying comorbidity
- Documentation of qualifying weight-related comorbid condition where applicable
- Documentation that member has been counseled to continue reduced-calorie diet and increased physical activity
- Attestation that requested agent will not be used in combination with another GLP-1 receptor agonist
- Requested quantity ≤ 4 pens/28 days
- For recertification: member weight within last 90 days AND one of: weight loss ≥ 5% from baseline, improvement in secondary measures with attestation, OSA symptom improvement with records verifying AHI ≥ 15, or CV risk reduction documentation with qualifying event
Quantity limits
- all strengths — 4 pens per 28 days
Approval and renewal
- Renewal: Weight loss ≥ 5% from baseline body weight; OR improvement in secondary measures with attestation that improvement is related to anti-obesity therapy; OR improvement in OSA symptoms (less daytime sleepiness, fewer sleep arousals, fewer partner-reported snoring/pauses) with attestation related to anti-obesity therapy and medical records verifying baseline or current OSA diagnosis with AHI ≥ 15; OR member requires a GLP-1 agent for cardiovascular risk reduction and benefit outweighs risk, with documented history of MI, ischemic or hemorrhagic stroke, or symptomatic PAD (intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease). Effective February 17, 2026, comorbid conditions and baseline BMI (prior to starting GLP-1) are used to determine continued eligibility; some members may no longer qualify at recertification.
Not covered when
- Combination use with another GLP-1 receptor agonist is not permitted (GLP-1/GIP polypharmacy requires separate PA and transitioning off prior agent)
- No pediatric coverage defined for Zepbound in this policy (adults ≥ 18 only)
- For pre-diabetes comorbidity pathway: member must not be a candidate for an anti-diabetic GLP-1 agent
Policy note: MassHealth (Massachusetts Medicaid) policy. Zepbound requires PA. Listed as 'tirzepatide-Zepbound' in the drug table. Policy criteria for Zepbound (obesity/overweight) are parallel to Wegovy adult criteria but with no tablet formulation and no pediatric indication covered. Pre-diabetes defined as A1C ≥ 5.7% and < 6.5%. OSA (moderate/severe) defined as AHI > 15 without central or mixed sleep apnea. Uncontrolled hypertension defined as systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite concurrent treatment with two antihypertensive medications. Recertification OSA pathway requires medical records verifying baseline OR current OSA diagnosis with AHI ≥ 15. Recertification CV pathway requires documented MI, ischemic or hemorrhagic stroke, or symptomatic PAD. Effective February 17, 2026, comorbid conditions and baseline BMI (prior to starting GLP-1) are used to determine continued eligibility. MassHealth pharmacy claims history may be used to evaluate adherence. Last revised 05/2026; page last updated 05/13/26.
Policy effective January 1, 2024 · verified June 4, 2026 · source: Massachusetts Medicaid Medicaid prior authorization policy · View policy document (PDF)