What BMI do you need for Zepbound under Ohio Medicaid?

For osa on Medicaid plans, Ohio Medicaid requires a BMI of 30 or higher.

How long does a Zepbound approval last with Ohio Medicaid?

Initial approvals last 12 months.

What does Ohio Medicaid require to renew Zepbound?

At least 5% weight loss from the starting weight and Renewal requires: (1a) Total AHI = 5% from baseline. AHI may be measured via home sleep apnea testing with a technically adequate device. Patient must also demonstrate 80% proportion of days covered (claims-based adherence). Prescriber must attest to ongoing safety and efficacy monitoring. Patient must not have type 1 or type 2 diabetes and HbA1c must be < 6.5% at renewal.

How current is this information?

This page reflects Ohio Medicaid's written policy as of its current version, last verified against the source document on June 4, 2026.

Does Ohio Medicaid cover Zepbound?

Zepbound for Osa

What Ohio Medicaid requires, by plan type. Open this indication on its own page →

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
A1C no higher than 6.5%
Diagnosis documented with a code
Prescribed by or in consultation with a specialist
Diagnosed obstructive sleep apnea (AHI of 15 or higher)
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial Approval — Moderate to Severe OSA in Adults with Obesity (No Diabetes)

All of:

Patient is 18 years of age or older
Diagnosis of moderate to severe OSA confirmed by in-lab sleep evaluation with polysomnography (PSG) within the last 12 months
Total apnea-hypopnea index (AHI) >= 15 events per hour on PSG
BMI >= 30 kg/m²
Patient does NOT have a history of type 1 or type 2 diabetes mellitus (if diabetes present, refer to Endocrine Agents: Diabetes – Non-Insulin Category of Ohio Medicaid's Unified PDL)
HbA1c < 6.5% (within the previous 6 months) — only required if patient has diabetes history (question 7 is conditional on Q6 being yes; if no diabetes, this confirms absence)
Prescriber attests patient has received instruction on reduced calorie diet and increased physical activity and is adherent
Patient will NOT receive additional GLP-1 receptor agonist or GIP medications concurrently with Zepbound
Zepbound is prescribed by or in consultation with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist

Renewal — Previously Approved PA within Last 365 Days

All of:

Patient has a previously approved PA from Gainwell within the last 365 days AND received Zepbound under Ohio Medicaid benefit (not samples) within the last 365 days
Positive clinical response: (Total AHI < 5) OR (Total AHI 5-14 with ESS <= 10); AND weight loss >= 5% from baseline
Patient adherent with Zepbound: 80% proportion of days covered (claims-based)
Prescriber attests to ongoing monitoring of patient safety and efficacy
Patient does not have type 1 or type 2 diabetes
HbA1c < 6.5% (current level and date of test required)

Documentation to bring

Diagnosis and ICD-10 code for moderate to severe OSA
In-lab polysomnography (PSG) results within the last 12 months confirming total AHI >= 15 events per hour
Patient AHI value listed on the form
Baseline BMI documentation (>= 30 kg/m²) including height, weight, and BMI
Documentation of patient's medical history regarding diabetes (type 1 or type 2)
HbA1c lab result within the previous 6 months (required if patient has diabetes history; < 6.5% required)
Prescriber attestation that patient has received instruction on reduced calorie diet and increased physical activity and is adherent
Prescriber attestation that patient will not receive concurrent GLP-1 receptor agonist or GIP medications
Documentation that Zepbound is prescribed by or in consultation with a neurologist, pulmonologist, otolaryngologist, or other sleep medicine specialist (list specialist name)
For renewal: Documentation of change in OSA status (AHI scores), ESS score (if applicable per criterion 1b), and body weight loss from baseline (>= 5%)
For renewal: Claims history supporting 80% proportion of days covered
For renewal: Prescriber attestation of ongoing safety and efficacy monitoring
For renewal: Chart notes/lab results showing patient does not have type 1 or type 2 diabetes and HbA1c < 6.5% with current date

Approval and renewal

Initial approval: 12 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Renewal requires: (1a) Total AHI < 5 OR (1b) Total AHI 5-14 with Epworth Sleepiness Scale (ESS) <= 10; AND (2) weight loss >= 5% from baseline. AHI may be measured via home sleep apnea testing with a technically adequate device. Patient must also demonstrate 80% proportion of days covered (claims-based adherence). Prescriber must attest to ongoing safety and efficacy monitoring. Patient must not have type 1 or type 2 diabetes and HbA1c must be < 6.5% at renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Type 2 diabetes mellitus (patients with diabetes are referred to the Endocrine Agents: Diabetes – Non-Insulin Category of Ohio Medicaid's Unified PDL)
HbA1c >= 6.5%
Concurrent use of other GLP-1 receptor agonist or GIP medications
Patients under 18 years of age (those under 21 may apply via EPSDT using the Standard PA Fillable form)
Weight loss / obesity treatment indication — Ohio Administrative Code 5160-9-03 excludes drugs used for treatment of obesity
Type 1 diabetes

Exceptions

ohio_epsdt: Patients under 21 years of age who may qualify under EPSDT provisions must submit via the Standard PA Fillable form at the Ohio Medicaid SPBM document library, not via this OSA-specific form.

Policy note: This PA form is specific to Ohio Medicaid (administered by Gainwell Technologies). OSA must be confirmed by IN-LAB polysomnography only (home sleep testing is NOT accepted for initial diagnosis; however, AHI for renewal/continuation may be measured via home sleep apnea testing with a technically adequate device). Zepbound for weight loss/obesity is explicitly NOT covered under Ohio Medicaid per OAC 5160-9-03. Patients with ANY history of diabetes (type 1 or type 2) are ineligible for this OSA indication and are redirected to the diabetes PDL. The HbA1c < 6.5% threshold applies both at initial approval (if diabetes history present) and at renewal (required documentation). The initial approval pathway implicitly covers 12 months given the renewal threshold of 365 days. The renewal/continuation re-checks the absence of diabetes and requires HbA1c < 6.5%, which are NOT waived at renewal.

verified June 4, 2026 · source: Pa policy

Why Zepbound requests get denied by Ohio Medicaid

Based on what this policy asks for. Fix these before the first submission.

Wrong brand for the diagnosis. Zepbound and Mounjaro are the same molecule with different approved uses; a request for Zepbound under a diagnosis that matches Mounjaro is routinely denied.
Diagnosis code missing or wrong on the request.
BMI not documented in the chart notes (or documented without a baseline weight and date).
Prescriber isn't the specialist the plan requires.
Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Ohio Medicaid cover Zepbound?: Ohio Medicaid covers Zepbound for osa with prior authorization on Medicaid.
What BMI do you need for Zepbound under Ohio Medicaid?: For osa on Medicaid plans, Ohio Medicaid requires a BMI of 30 or higher.
How long does a Zepbound approval last with Ohio Medicaid?: Initial approvals last 12 months.
What does Ohio Medicaid require to renew Zepbound?: At least 5% weight loss from the starting weight and Renewal requires: (1a) Total AHI < 5 OR (1b) Total AHI 5-14 with Epworth Sleepiness Scale (ESS) <= 10; AND (2) weight loss >= 5% from baseline. AHI may be measured via home sleep apnea testing with a technically adequate device. Patient must also demonstrate 80% proportion of days covered (claims-based adherence). Prescriber must attest to ongoing safety and efficacy monitoring. Patient must not have type 1 or type 2 diabetes and HbA1c must be < 6.5% at renewal.
How current is this information?: This page reflects Ohio Medicaid's written policy as of its current version, last verified against the source document on June 4, 2026.