Applies to Medicaid plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Pediatric (age 12–17): BMI-based
All of:
- Participant is aged 12–17 years
- BMI ≥ 95th percentile standardized for age and sex
- Claim is for preferred agent OR documented medical necessity for non-preferred agent
Adult (age ≥ 18): BMI ≥ 30
All of:
- Participant is aged ≥ 18 years
- Documented baseline BMI ≥ 30 kg/m2
- Claim is for preferred agent OR documented medical necessity for non-preferred agent
Adult (age ≥ 18): BMI ≥ 27 with comorbidity
All of:
- Participant is aged ≥ 18 years
- Documented baseline BMI ≥ 27 kg/m2
- Claim is for preferred agent OR documented medical necessity for non-preferred agent
Plus any one of:
- Hypertension
- Dyslipidemia
- Obstructive sleep apnea
- Pre-diabetes (A1C 5.7–6.4%, fasting glucose 100–125 mg/dL, or 2-hr OGTT 140–199 mg/dL)
- Previous myocardial infarction
- Previous stroke
- Symptomatic peripheral arterial disease (intermittent claudication with ABI < 0.85, peripheral arterial revascularization, or amputation due to ASCVD)
- Type 2 diabetes mellitus
Adult (age ≥ 18): MASH with F2 or F3 fibrosis
All of:
- Participant is aged ≥ 18 years
- Recent liver biopsy or noninvasive techniques confirming MASH with F2 or F3 fibrosis
- Claim is for preferred agent OR documented medical necessity for non-preferred agent
Continuation: Documented compliance with current preferred agent therapy
All of:
- Documented compliance to current preferred agent therapy
Concurrent antipsychotic therapy
All of:
- Documented concurrent therapy with antipsychotic therapy
Documentation to bring
- Participant age documentation (≥ 12 years)
- For ages 12–17: Documented baseline BMI ≥ 95th percentile standardized for age and sex
- For ages ≥ 18 with BMI ≥ 30: Documented baseline BMI ≥ 30 kg/m2
- For ages ≥ 18 with BMI ≥ 27: Documented baseline BMI ≥ 27 kg/m2 AND documentation of at least one qualifying comorbidity (hypertension, dyslipidemia, OSA, pre-diabetes with lab evidence, prior MI, prior stroke, symptomatic PAD, or T2DM)
- For MASH pathway: Recent liver biopsy or noninvasive techniques confirming MASH with F2 or F3 fibrosis
- If non-preferred agent: Documentation of medical necessity explaining why preferred agent cannot be utilized
- If continuation: Documentation of compliance with current preferred agent therapy
- If antipsychotic pathway: Documentation of concurrent antipsychotic therapy
Quantity limits
- 2.5 mg/0.5 mL pen, 2.5 mg/0.5 mL vial, 5 mg/0.5 mL pen, 5 mg/0.5 mL vial, 7.5 mg/0.5 mL pen, 10 mg/0.5 mL pen, 12.5 mg/0.5 mL pen, 15 mg/0.5 mL pen — 2 mL per 28 days
Not covered when
- Concurrent therapy with another GLP-1 receptor agonist
Policy note: Zepbound is the preferred agent on the MO HealthNet PDL for GLP-1 agonists indicated for obesity. Default approval period is 1 year 90 days. Denial exception code '0160' (Preferred Drug List). GLP-1 receptor agonists indicated only for anti-obesity but not listed in this policy remain excluded from MO HealthNet coverage. GLP-1 agonists indicated for diabetes are covered under a separate PDL edit. No titration/dosing escalation monitoring requirements are specified for Zepbound in this document (only for Wegovy).
Policy effective January 29, 2026 · verified June 3, 2026 · source: Policy 311 · View policy document (PDF)