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Michigan Medicaid

Does Michigan Medicaid cover Zepbound?

Yes. Michigan Medicaid covers Zepbound for weight loss with prior authorization if your BMI is 40 or higher. Other policy requirements and your plan's benefits also apply.

Policy documents

  • Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review June 4, 2026. How we verify · Check your exact plan · Medicaid card names in Michigan

Full requirements: Zepbound for Weight Loss (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Step therapy: allergy, contraindication, DDI, side effects, or trial-and-failure of all five preferred agent types

Plus any one of:

  • Allergy to all five types of preferred medications (benzphetamine, diethylpropion, orlistat, phendimetrazine, phentermine)
  • Contraindication or drug-to-drug interaction with all five types of preferred medications
  • History of unacceptable side effects with all five types of preferred medications
  • Trial and failure with all five types of preferred agents (at least one orlistat agent, one phentermine product, plus benzphetamine, diethylpropion, and phendimetrazine)

Initial approval — additional medication-specific criteria (all required)

All of:

  • Patient age ≥18 years
  • Patient has an initial BMI classified as morbidly obese (BMI ≥40 kg/m²)
  • Prescriber attests patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attests documented failure of all other clinically appropriate weight loss interventions
  • Prescriber attests use of GLP-1 for weight loss is to avert the need for higher-cost bariatric surgery
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
  • Prescriber attests to absence of contraindications including pregnancy, lactation, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type II
  • Prescriber attests medication therapy is part of a total treatment plan including diet and exercise/activity
  • Prescriber attests patient has been informed weight may return with cessation unless lifestyle changes are permanently adopted
  • Prescriber attests metabolic or other reasons for obesity/symptoms have been ruled out or diagnosed and treated (e.g., thyroid dysfunction, diabetes, sleep apnea)
  • For patients with an eating disorder: prescriber attests treatment has been optimized and confirms safety and appropriateness

Documentation to bring

  • Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attestation of documented failure of all other clinically appropriate weight loss interventions
  • Prescriber attestation that use of GLP-1 is to avert the need for higher-cost bariatric surgery
  • Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP-4 inhibitor
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN2)
  • Prescriber attestation that medication is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been informed about weight return upon cessation
  • Prescriber attestation that metabolic or other causes of obesity have been ruled out or treated
  • For patients with eating disorder: prescriber attestation that treatment has been optimized
  • Documentation of step therapy: allergy, contraindication, DDI, unacceptable side effects, or trial-and-failure of all five preferred agent types (benzphetamine, diethylpropion, orlistat, phendimetrazine, phentermine)
  • Baseline BMI documentation (≥40 kg/m²) for patients ≥18 years
  • Renewal — patients ≥18: clinical documentation of weight at renewal showing ≥5% weight loss from baseline

Quantity limits

  • 2.5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 7.5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 10 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 12.5 mg/0.5 mL pens — 2 mL (4 pens) per 28 days
  • 15 mg/0.5 mL pens — 2 mL (4 pens) per 28 days
  • KwikPen 2.5 mg/dose (10 mg/2.4 mL), KwikPen 5 mg/dose (10 mg/2.4 mL), KwikPen 7.5 mg/dose (10 mg/2.4 mL), KwikPen 10 mg/dose (10 mg/2.4 mL), KwikPen 12.5 mg/dose (10 mg/2.4 mL), KwikPen 15 mg/dose (10 mg/2.4 mL) — 2.4 mL (1 KwikPen) per 28 days

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: For patients ≥18 years: must have maintained weight loss of ≥5% from baseline weight at initiation of therapy. For 1st renewal of established members with initial approval prior to 1/1/2026: prescriber attests to morbid obesity at start, documented failure of all other weight loss interventions, and use was to avert bariatric surgery, plus same weight maintenance requirement.

Not covered when

  • Lactation
  • Personal or family history of medullary thyroid cancer
  • Personal or family history of multiple endocrine neoplasia type II
  • Concurrent use of a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, sitagliptin)
  • Concurrent use of another anti-obesity GLP-1 agonist
  • Patients under age 18 (Zepbound minimum age is 18 per this policy)
  • Pregnancy

Policy note: This policy applies to 'non-preferred GLP-1s only' for weight loss under Michigan Medicaid PDL. Zepbound (tirzepatide) minimum age per this policy is 18 years. The morbidly obese BMI threshold for adults is ≥40 kg/m²; the policy does not apply the 12-year minimum or pediatric BMI percentile pathway to Zepbound (only to Wegovy and Saxenda/liraglutide). MDHHS recommends prescribers consider the benefits of a diabetes prevention program. A special 1st renewal pathway exists for established members with initial approval prior to 1/1/2026 requiring attestations of morbid obesity at start, documented failure of other interventions, and use to avert bariatric surgery, plus the standard ≥5% weight loss requirement.

Policy effective July 1, 2026 · verified June 4, 2026 · source: Mi Rx Clinical Criteria · View policy document (PDF)

Open on its own page →

Full requirements: Zepbound for Obstructive Sleep Apnea (OSA) (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Initial approval for OSA

All of:

  • Patient is ≥ 18 years of age
  • Initial BMI ≥ 27 kg/m²
  • Documented diagnosis of moderate to severe obstructive sleep apnea (OSA)
  • Prescriber attests patient will not use Zepbound concurrently with another GLP-1 agonist
  • Prescriber attests patient will not use Zepbound concurrently with a non-GLP-1 weight loss medication
  • Prescriber attests patient will not use Zepbound concurrently with a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
  • For patients with an eating disorder: prescriber attests treatment has been optimized and confirms safety and appropriateness
  • Prescriber attests metabolic or other reasons for obesity/symptoms have been ruled out or diagnosed and treated (e.g., thyroid dysfunction, diabetes)
  • Prescriber attests to absence of contraindications including pregnancy, lactation, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type II
  • Prescriber attests medication therapy is part of a total treatment plan including diet and exercise/activity as appropriate
  • Prescriber attests patient has been informed weight may return with cessation of medication unless healthy lifestyle changes are permanently adopted

Renewal/continuation for OSA

All of:

  • Patient is currently established on Zepbound for moderate to severe OSA
  • Clinical documentation demonstrating ≥ 5% weight loss from baseline weight at initiation of therapy

Documentation to bring

  • Prescriber attestation that patient will not use Zepbound concurrently with another GLP-1 agonist
  • Prescriber attestation that patient will not use Zepbound concurrently with a non-GLP-1 weight loss medication
  • Prescriber attestation that patient will not use Zepbound concurrently with a DPP-4 inhibitor
  • Documentation of patient age ≥ 18 years
  • Baseline BMI documentation (≥ 27 kg/m²)
  • Documented diagnosis of moderate to severe obstructive sleep apnea (OSA)
  • For patients with eating disorder: prescriber attestation that treatment has been optimized and is safe/appropriate
  • Prescriber attestation that metabolic or other causes of obesity have been ruled out or treated
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal/family history of medullary thyroid cancer or MEN type II)
  • Prescriber attestation that therapy is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been counseled on weight regain risk upon cessation
  • [Renewal] Clinical documentation of current weight showing ≥ 5% weight loss from baseline

Quantity limits

  • 2.5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 7.5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 10 mg/0.5 mL — 2 mL (4 pens/vials)
  • 12.5 mg/0.5 mL — 2 mL (4 pens)
  • 15 mg/0.5 mL — 2 mL (4 pens)

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • Renewal: Prescriber must provide clinical documentation showing the patient has maintained a weight loss of ≥ 5% from baseline weight at initiation of therapy. Patient must be currently established on the medication for the OSA diagnosis.

Not covered when

  • Lactation
  • Personal or family history of medullary thyroid cancer
  • Multiple endocrine neoplasia type II (MEN2)
  • Concurrent use of another GLP-1 agonist
  • Concurrent use of a non-GLP-1 weight loss medication
  • Concurrent use of a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, sitagliptin)
  • Pregnancy

Policy note: This is Michigan Medicaid (MDHHS) criteria managed by Prime Therapeutics. The OSA indication requires 'moderate to severe' OSA but no specific AHI threshold is stated. The policy does not require PAP/CPAP therapy trial prior to approval. MDHHS recommends (but does not require) that prescribers consider referring patients to a diabetes prevention program. The 12.5 mg and 15 mg strengths are listed as 'pens' only (no vials option). For renewal, only the 5% weight loss maintenance is required — BMI threshold, OSA diagnosis attestation, and concurrent medication restrictions are not explicitly re-verified at renewal per the stated renewal criteria.

Policy effective July 1, 2026 · verified June 4, 2026 · source: Mi Rx Clinical Criteria · View policy document (PDF)

Open on its own page →

Questions people ask
Does Michigan Medicaid cover Zepbound?
Yes. Michigan Medicaid covers Zepbound for weight loss with prior authorization if your BMI is 40 or higher. Other policy requirements and your plan's benefits also apply.
How long does a Zepbound approval last with Michigan Medicaid?
Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does Michigan Medicaid require to renew Zepbound?
Weight Loss — Applies to Medicaid plans. For patients ≥18 years: must have maintained weight loss of ≥5% from baseline weight at initiation of therapy. For 1st renewal of established members with initial approval prior to 1/1/2026: prescriber attests to morbid obesity at start, documented failure of all other weight loss interventions, and use was to avert bariatric surgery, plus same weight maintenance requirement. Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. Prescriber must provide clinical documentation showing the patient has maintained a weight loss of ≥ 5% from baseline weight at initiation of therapy. Patient must be currently established on the medication for the OSA diagnosis.
How current is this information?
The oldest review date among the policies on this page is June 4, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Card and program names on file in Michigan

These names map to Michigan Medicaid, including older names and spelling variants. This is not a list of plans currently accepting members.

Also under Michigan Medicaid: Mounjaro, Ozempic, Wegovy

Zepbound under other plans: BCBS Michigan, Molina Healthcare, Priority Health, Alabama Medicaid, California Medicaid, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid

All insurance plans · All medications

Summary of Michigan Medicaid's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.