Massachusetts Medicaid coverage for Zepbound (Weight Loss)

What you need to qualify

• Age 18 and older
• BMI of 35 or higher
• BMI of 27 or higher with a weight-related condition (heart failure with preserved ejection fraction, uncontrolled hypertension, CKD stage 3a or above, OSA, pre-diabetes, MI, stroke, MASH with moderate to advanced liver fibrosis, symptomatic peripheral artery disease, and T2DM)

Qualification pathways

You can qualify through any one of these.

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

• To renew, the plan looks for at least 5% weight loss from the starting weight and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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: Pa policy