Michigan Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
Diagnosed obstructive sleep apnea

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

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: MIRx_clinical_criteria.pdf