New Hampshire Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
3 months of a documented diet and exercise program
Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial Approval — OSA with Obesity

All of:

Documented failure of at least a three-month trial on a low-calorie diet (1,200 kcal/day for women, 1,600 kcal/day for men)
Regimen of increased physical activity including strength training to prevent lean muscle loss (unless medically contraindicated by comorbidity)
Baseline BMI >= 27 kg/m²
Diagnosis of moderate-to-severe OSA confirmed by AHI >= 15 on in-lab attended sleep study or polysomnography (PSG)
Patient has been adherent to PAP therapy at least 70% of the time in the last 6 months and will continue PAP in combination with tirzepatide (unless intolerant or other rationale provided)
Patient does not have a diagnosis of Type 1 or Type 2 Diabetes Mellitus

Renewal — Ongoing OSA Treatment

All of:

Ongoing prescriber documentation of adherence to low-calorie diet (1,200 kcal/day for women, 1,600 kcal/day for men)
Ongoing regimen of increased physical activity and strength training (unless medically contraindicated by comorbidity)
Ongoing adherence to PAP therapy
Patient has not experienced any treatment-restricting adverse effects (e.g., diarrhea, nausea, vomiting, GERD)

Documentation to bring

Documentation of failure of at least a 3-month low-calorie diet trial (1,200 kcal/day for women, 1,600 kcal/day for men)
Documentation of current regimen of increased physical activity including strength training, or medical contraindication
Baseline BMI measurement >= 27 kg/m²
Sleep study or polysomnography (PSG) results confirming AHI >= 15 (moderate-to-severe OSA)
Documentation of PAP therapy adherence >= 70% over the last 6 months, or documentation of PAP intolerance or clinical rationale for non-use
Confirmation that patient does not have a diagnosis of Type 1 or Type 2 Diabetes Mellitus
For renewal: prescriber attestation of ongoing diet and exercise adherence
For renewal: documentation of ongoing PAP therapy adherence
For renewal: documentation of absence of treatment-restricting adverse effects

Approval and renewal

Initial approval: 6 months
Renewal: every 12 months
To renew, the plan looks for Ongoing prescriber documentation of adherence to low-calorie diet (1,200 kcal/day for women, 1,600 kcal/day for men); ongoing regimen of increased physical activity and strength training (unless medically contraindicated); ongoing adherence to PAP therapy; no treatment-restricting adverse effects (e.g., diarrhea, nausea, vomiting, GERD). Note: initial BMI threshold, OSA diagnosis confirmation, PAP prior trial, and diabetes exclusion are not explicitly re-verified at renewal — only ongoing adherence to diet, exercise, and PAP therapy is required.

Not covered when

Type 2 Diabetes Mellitus (patient must not have diagnosis of T1DM or T2DM)
Use solely for chronic weight management (not OSA) is denied
Type 1 diabetes

Policy note: This policy is specific to New Hampshire Medicaid Fee-for-Service and was administered/drafted by Prime Therapeutics. OSA must be moderate-to-severe (AHI >= 15). PAP adherence is defined as >= 70% over the last 6 months; exceptions allowed for documented PAP intolerance or other provided rationale. The policy explicitly excludes both T1DM and T2DM patients. Claims solely for chronic weight management (without OSA indication) will be denied. Dosage forms listed: 2.5 mg/0.5 mL, 5 mg/0.5 mL, 7.5 mg/0.5 mL, 10 mg/0.5 mL, 12.5 mg/0.5 mL, 15 mg/0.5 mL. No quantity limits specified in this document.

Policy effective October 1, 2025 · verified June 4, 2026 · source: e0959ae6-9462-96ed-f65f-513497f0cd3c