Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- 6 months of a documented diet and exercise program
- Diagnosed obstructive sleep apnea
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
- To renew, the plan looks for 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: download