North Dakota Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

BMI of 30 or higher
6 months of a documented diet and exercise program
Prior trial of another GLP-1 medication (semaglutide) for at least 180 days
Prior trial of semaglutide, phentermine, bupropion, naltrexone, and topiramate for at least 6 months
Prescribed by or in consultation with a specialist
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.

Zepbound (tirzepatide) for moderate-to-severe OSA in obese, non-diabetic patients

All of:

Requested medication prescribed by or in consult with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist
Diagnosis of moderate to severe OSA defined as AHI >15 determined by in-lab attended sleep study or polysomnography (PSG)
Member does NOT have type 2 diabetes
Diagnosis of obesity (BMI ≥30 kg/m2)
Failed a 6-month trial of continuous positive airway pressure (CPAP) along with the weight management program within the past year, as evidenced by AHI >15
Member must meet FDA-approved label for use
Documentation of participation in a comprehensive weight management program including behavioral modification, reduced-calorie diet, increased physical activity, and pharmacotherapy with semaglutide for at least 6 months (or phentermine/bupropion/naltrexone/topiramate if semaglutide not tolerated)
If member qualifies for tirzepatide, the most cost-effective tirzepatide product will be authorized

Documentation to bring

Sleep study or polysomnography (PSG) result confirming AHI >15 (moderate to severe OSA)
Documentation of BMI ≥30 kg/m2
Documentation confirming absence of type 2 diabetes
Documentation of failed 6-month CPAP trial (AHI still >15)
Documentation of participation in comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) for at least 6 months within the past year
Documentation of pharmacotherapy with semaglutide for at least 6 months within the weight management program (or phentermine if semaglutide not tolerated; or bupropion/naltrexone/topiramate if phentermine cannot be used)
Prescriber attestation from neurologist, pulmonologist, otolaryngologist, or sleep medicine specialist

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 10% weight loss from the starting weight and Member has demonstrated clinical response evidenced by any of: (1) decrease in AHI determined by PSG ≥20%, or change in OSA severity status to Remission or Mild Non-Symptomatic OSA (AHI <5 or AHI 5-14 AND Epworth Sleepiness Scale ≤10); OR (2) weight loss from baseline ≥10%. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Type 2 diabetes is an EXPLICIT exclusion for Zepbound OSA indication
AHI ≤15 (mild OSA) does not qualify
BMI <30 does not qualify

Policy note: Zepbound (tirzepatide) for OSA is PA REQUIRED. Key features: (1) Type 2 diabetes explicitly excluded - this is the OSA-specific tirzepatide indication; (2) Requires formal comprehensive weight management program including pharmacotherapy with semaglutide for 6 months (this IS a formal program requirement, not just label language); (3) CPAP trial failure required (6 months); (4) Moderate-to-severe OSA confirmed by PSG with AHI >15; (5) BMI ≥30 kg/m2 required; (6) Specialist required. For continuation: AHI reduction ≥20% or OSA severity improvement, OR ≥10% weight loss from baseline. Note: Mounjaro can be approved under Pathway B of the diabetes criteria if member qualifies for tirzepatide OSA criteria - the most cost-effective tirzepatide will be authorized.

Policy effective April 1, 2026 · verified June 3, 2026 · source: PDL-2026.4.pdf