Michigan Medicaid coverage for Zepbound (Weight

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 40 or higher
Prior trial of benzphetamine, diethylpropion, orlistat, phendimetrazine, and phentermine

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
To renew, the plan looks for at least 5% weight loss from the starting weight and 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. 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
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: MIRx_clinical_criteria.pdf

Michigan Medicaid coverage for Zepbound (Weight Loss)