Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (HTN, T2DM, OSA, CVD, and dyslipidemia)
- 6 months of a documented diet and exercise program
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
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and 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+). Make sure your starting weight and date are in the chart now — renewal is measured against it.
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: download