Nevada Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
Diagnosed obstructive sleep apnea (AHI of 5 or higher)
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

OSA with obesity - AHI >= 15 (moderate to severe)

All of:

Adult age >= 18 years
BMI > 30 kg/m2
Moderate to severe OSA in adults with obesity
15 or more obstructive respiratory events per hour of sleep confirmed by sleep study from certified or accredited sleep disorder facility
No type 1 or type 2 diabetes
No contraindications to Zepbound
Full compliance with ongoing treatment for underlying airway obstruction (e.g., CPAP, BiPAP) unless provider rationale for why not indicated
Provider attestation medication used with reduced calorie diet and increased physical activity

OSA with obesity - AHI >= 5 with symptoms (mild to moderate)

All of:

Adult age >= 18 years
BMI > 30 kg/m2
Moderate to severe OSA in adults with obesity
5 or more obstructive respiratory events per hour of sleep confirmed by sleep study from certified or accredited sleep disorder facility
No type 1 or type 2 diabetes
No contraindications to Zepbound
Full compliance with ongoing treatment for underlying airway obstruction (e.g., CPAP, BiPAP) unless provider rationale for why not indicated
Provider attestation medication used with reduced calorie diet and increased physical activity

Plus any one of:

Daytime sleepiness
Nonrestorative sleep
Fatigue
Insomnia
Waking up with breath holding, gasping, or choking
Habitual snoring noted by bed partner or other observer
Observed apnea

OSA with obesity - Unable to undergo facility sleep study

All of:

Adult age >= 18 years
BMI > 30 kg/m2
Moderate to severe OSA in adults with obesity
Recipient is not an appropriate candidate for a facility sleep study due to immobility, safety, or critical illness
Zepbound prescribed by or in consultation with a board-certified sleep specialist or pulmonologist for diagnosis of moderate to severe OSA
No type 1 or type 2 diabetes
No contraindications to Zepbound
Full compliance with ongoing treatment for underlying airway obstruction (e.g., CPAP, BiPAP) unless provider rationale for why not indicated
Provider attestation medication used with reduced calorie diet and increased physical activity

Documentation to bring

Documentation of BMI > 30 kg/m2
Submission of sleep study records confirming OSA from a certified or accredited sleep disorder facility (for pathways 1 and 2), OR documentation that facility sleep study is not appropriate with specialist consultation (pathway 3)
Documentation of AHI (obstructive respiratory events per hour of sleep)
Documentation of qualifying OSA symptoms if AHI is 5-14 (pathway 2)
Board-certified sleep specialist or pulmonologist consultation if facility sleep study not feasible (pathway 3)
Confirmation recipient has no type 1 or type 2 diabetes
Confirmation of no contraindications to Zepbound
Documentation of compliance with CPAP/BiPAP or provider rationale for why PAP therapy is not indicated
Provider attestation that medication will be used with reduced calorie diet and increased physical activity

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for Documentation of positive clinical response to therapy; recipient continues to be fully compliant with ongoing PAP/BiPAP treatment for underlying airway obstruction (unless provider rationale given why not indicated). T2DM exclusion and BMI requirement not explicitly re-checked at continuation.

Not covered when

Type 2 diabetes (this OSA indication is specific to non-diabetic recipients)
Any contraindications to Zepbound use
Type 1 diabetes

Policy note: osa_ahi_min is set to 5 reflecting the minimum AHI threshold in any qualifying pathway (pathway 2 allows AHI >= 5 with symptoms). Pathway 1 requires AHI >= 15 without additional symptom requirement. PAP therapy (CPAP/BiPAP) compliance is required ongoing but is NOT a prior trial requirement for initial approval — it must be ongoing concurrent treatment. Policy requires submission of records (sleep study records). Recertification at 6 months requires positive clinical response and continued PAP compliance. Both T1DM and T2DM are explicitly excluded — this indication is for non-diabetic patients only.

Policy effective April 6, 2026 · verified June 3, 2026 · source: msm_1200_26_04_06.pdf