Yes. North Carolina Medicaid covers Zepbound for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
Policy on file; the document isn't available to view online yet.
Medicaid: Covered with requirements. See the qualification pathways below.
Full requirements: Zepbound for Weight Loss (1 plan type)›
Applies to Medicaid plans.
Covered with requirements
Qualification pathways
You can qualify through any one of these.
Adult (18+) — BMI ≥ 30
All of:
Age 18 or older
BMI ≥ 30 kg/m²
FDA approved for indication, age, weight, and does not exceed dosing limits
Preferred drug trial completed (3–6 months titration) unless contraindicated or meets non-preferred PDL PA criteria
Baseline weight and BMI documented within past 45 days on PA form
Beneficiary is new to therapy or attempting a repeat weight loss course
Currently on and will continue lifestyle modification (structured nutrition and physical activity)
Will NOT use in combination with another GLP-1 receptor agonist
No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Adult (18+) — BMI ≥ 27 with comorbidity
All of:
Age 18 or older
BMI ≥ 27 kg/m²
At least one weight-related comorbidity/risk factor/complication (hypertension, type 2 diabetes, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
FDA approved for indication, age, weight, and does not exceed dosing limits
Preferred drug trial completed (3–6 months titration) unless contraindicated or meets non-preferred PDL PA criteria
Baseline weight and BMI documented within past 45 days on PA form
Beneficiary is new to therapy or attempting a repeat weight loss course
Currently on and will continue lifestyle modification (structured nutrition and physical activity)
Will NOT use in combination with another GLP-1 receptor agonist
No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Documentation to bring
Baseline weight and BMI (measured within the past 45 days) documented on PA form
Documentation of preferred drug trial (3–6 months titration) or documented contraindication to preferred drug
Documentation that beneficiary is new to therapy or attempting a repeat weight loss course
For BMI ≥ 27 with comorbidity pathway: documentation of qualifying weight-related comorbidity
Quantity limits
all strengths — 2 mL per 28 days
Approval and renewal
Initial approval: 6 months
Renewal: every 12 months
Renewal: At least 5% weight loss from the starting weight.
Renewal: At least 4% reduction in BMI.
Renewal: Adults: 5% total pretreatment weight loss maintained. Adolescents (12 to <18): >4% reduction in baseline BMI maintained. Alternatively, documented weight loss deemed significant per prescriber even if thresholds not met (with rationale). Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. At each renewal, provider must document review of medication list for possible dose reductions or discontinuation of comorbid medications no longer needed due to weight reduction effects. Note: Zepbound for weight loss is only approved for adults (18+).
Not covered when
Lactation
History of medullary thyroid carcinoma
Multiple endocrine neoplasia syndrome type 2 (MEN2)
Concurrent use with another GLP-1 receptor agonist
Patients under 18 years of age (Zepbound is 18 and over only)
Pregnancy
Policy note: Zepbound for weight loss is restricted to adults 18 and over, unlike Wegovy which has a lower age limit of 12. The general weight management policy also allows adults ≥ 45 with BMI ≥ 27 and established CVD (MI, stroke, symptomatic peripheral disease) as a qualifying pathway. Renewal duration is 12 months per the general weight management renewal section.
Policy effective August 1, 2024 · verified June 4, 2026 · source: North Carolina Medicaid Medicaid prior authorization policy
Full requirements: Zepbound for Obstructive Sleep Apnea (OSA) (1 plan type)›
Applies to Medicaid plans.
Covered with requirements
Qualification pathways
You can qualify through any one of these.
Moderate to Severe OSA in Adult with Obesity
All of:
Diagnosis of moderate to severe obstructive sleep apnea (OSA) — confirmed by sleep apnea testing (documentation required with PA request)
Adult (18 years of age or over)
Documented baseline BMI > 30 kg/m² prior to beginning therapy
Obesity as a comorbid condition
Beneficiary instructed on sleep hygiene modifications before beginning Zepbound (sleep positioning, avoidance of alcohol and stimulants before bed)
FDA approved for indication, age, weight, and does not exceed dosing limits
Currently on and will continue lifestyle modification (structured nutrition and physical activity)
Will NOT use in combination with another GLP-1 receptor agonist
No FDA-labeled contraindications (including pregnancy, lactation, medullary thyroid cancer history, MEN2)
Documentation to bring
Documentation confirming sleep apnea testing was performed and moderate to severe OSA was diagnosed (must be submitted with PA request)
Documented baseline BMI > 30 kg/m² prior to beginning therapy
Documentation that beneficiary was instructed on sleep hygiene modifications before beginning Zepbound
Quantity limits
all strengths — 2 mL per 28 days
Approval and renewal
Initial approval: 6 months
Renewal: every 6 months
Renewal: Medical documentation that beneficiary has improved while on medication AND individual clinical goals set by provider are being met OR beneficiary is continuing to make adequate progress towards treatment goals. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. Provider must document review of medication list at each renewal for possible dose reductions or discontinuation of comorbid medications. Note: Covered indication went into effect October 1, 2025; prior PA approval through Medicaid required before renewal.
Not covered when
Lactation
History of medullary thyroid carcinoma
Multiple endocrine neoplasia syndrome type 2 (MEN2)
Concurrent use with another GLP-1 receptor agonist
Patients under 18 years of age
Pregnancy
Policy note: Policy requires documentation of moderate to severe OSA via sleep apnea testing submitted with PA request. The policy specifies 'moderate to severe' OSA but does not provide a numeric AHI threshold; AHI classification is per standard sleep medicine criteria. Policy does not explicitly require a prior PAP/CPAP trial for Zepbound OSA indication. Sleep hygiene instruction prior to therapy is required. Covered indication went into effect October 1, 2025 per the renewal criteria section. Duration of approval is 6 months for both initial and renewals for the OSA indication.
Policy effective August 1, 2024 · verified June 4, 2026 · source: North Carolina Medicaid Medicaid prior authorization policy
Yes. North Carolina Medicaid covers Zepbound for weight loss with prior authorization if your BMI is 30 or higher, or 27 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
How long does a Zepbound approval last with North Carolina Medicaid?
Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 12 months. Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does North Carolina Medicaid require to renew Zepbound?
Weight Loss — Applies to Medicaid plans. At least 5% weight loss from the starting weight. At least 4% reduction in BMI. Adults: 5% total pretreatment weight loss maintained. Adolescents (12 to <18): >4% reduction in baseline BMI maintained. Alternatively, documented weight loss deemed significant per prescriber even if thresholds not met (with rationale). Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. At each renewal, provider must document review of medication list for possible dose reductions or discontinuation of comorbid medications no longer needed due to weight reduction effects. Note: Zepbound for weight loss is only approved for adults (18+). Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. Medical documentation that beneficiary has improved while on medication AND individual clinical goals set by provider are being met OR beneficiary is continuing to make adequate progress towards treatment goals. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. Provider must document review of medication list at each renewal for possible dose reductions or discontinuation of comorbid medications. Note: Covered indication went into effect October 1, 2025; prior PA approval through Medicaid required before renewal.
How current is this information?
The oldest review date among the policies on this page is June 4, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.
