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Oregon Medicaid

Does Oregon Medicaid cover Zepbound?

No. Oregon Medicaid's policies on file exclude Zepbound for weight loss on Medicaid plans.

Policy document

  • Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026

    Oregon Medicaid · PA policy · Medicaid

    Effective March 1, 2026. Verified June 4, 2026.

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  • Medicaid: Not covered. Document explicitly states: 'Tirzepatide is not currently covered for adults who do not have established ob...

Earliest policy review June 4, 2026. How we verify · Check your exact plan

Full requirements: Zepbound for Weight Loss (1 plan type)

Applies to Medicaid plans.

Not covered

Document explicitly states: 'Tirzepatide is not currently covered for adults who do not have established obstructive sleep apnea or type 2 diabetes.' Additionally: 'Drugs prescribed for only weight management (overweight or obesity) are NOT currently covered' (Table 3 note). Step 12 denial language: 'drugs are not covered by OHP for adults when indicated for weight loss.'

Policy note: Zepbound (tirzepatide) is explicitly not covered for adults when indicated solely for weight loss/obesity/overweight without an evidence-supported indication (OSA or T2DM). This applies to the Oregon Health Plan (Oregon Medicaid). Note: pediatric weight loss (EPSDT) coverage via Zepbound is not applicable as Table 1 indicates Zepbound (tirzepatide) is not FDA-approved for pediatrics.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026 · View policy document (PDF)

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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.

OSA — Moderate to Severe OSA with Obesity

All of:

  • Patient is an adult (implied: 18 years or older based on Table 3 and approval criteria flow)
  • BMI of 30 kg/m2 or greater (obesity)
  • Moderate to severe obstructive sleep apnea (OSA): AHI of 15 events/hour or more
  • Prior weight loss treatment plan administered by a health care provider for at least 3 months within the previous 6-month timeframe
  • Patient will be engaged in a weight management lifestyle modification program in addition to pharmacotherapy
  • Patient has been screened for diabetes within the past year with results indicating no diabetes (HbA1c <6.5% or fasting blood glucose <126 mg/dL) OR has a documented type 2 diabetes diagnosis

Documentation to bring

  • ICD-10 diagnosis code for the condition being treated
  • Documentation of obesity (BMI ≥30 kg/m2)
  • Documentation of moderate to severe OSA diagnosis with AHI ≥15 events/hour
  • Documentation of prior weight loss treatment plan administered by a health care provider for at least 3 months within the previous 6-month timeframe
  • Documentation of type 2 diabetes diagnosis OR diabetes screening results within the past year (HbA1c <6.5% or fasting blood glucose <126 mg/dL)
  • Attestation that patient will be engaged in a weight management lifestyle modification program

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • Renewal: At least 5% reduction in BMI.
  • Renewal: At renewal for OSA (step 5-8): patient must have lost or maintained a BMI reduction of 5% or more, been adherent to therapy per provider attestation, and be continuing with a weight loss treatment plan (diet/exercise, nutritional counseling, and/or calorie restricted diet). BMI, OSA diagnosis, and T2DM screening are not re-verified at renewal.

Policy note: Moderate OSA defined as AHI ≥15 events/hour; severe OSA defined as AHI ≥30 events/hour. The document does not require PAP therapy trial prior to approval. The OSA approval pathway flows through the Table 3 evidence-supported indications check (step 12) and then step 13 (lifestyle program), step 14/15 (diabetes screening), and step 16/17 (Zepbound-specific OSA criteria). The document states 'Tirzepatide is not currently covered for adults who do not have established obstructive sleep apnea or type 2 diabetes.' No PAP/CPAP trial requirement was stated.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20 Medicaid%20 PA%20 Criteria%20 Guide%20 %20 June%201%2 C%202026 · View policy document (PDF)

Open on its own page →

If weight loss isn't covered on your plan

Oregon Medicaid has separate Zepbound policies that don't depend on that benefit:

Questions people ask
Does Oregon Medicaid cover Zepbound?
No. Oregon Medicaid's policies on file exclude Zepbound for weight loss on Medicaid plans.
How long does a Zepbound approval last with Oregon Medicaid?
Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 12 months.
What does Oregon Medicaid require to renew Zepbound?
Obstructive Sleep Apnea (OSA) — Applies to Medicaid plans. At least 5% reduction in BMI. At renewal for OSA (step 5-8): patient must have lost or maintained a BMI reduction of 5% or more, been adherent to therapy per provider attestation, and be continuing with a weight loss treatment plan (diet/exercise, nutritional counseling, and/or calorie restricted diet). BMI, OSA diagnosis, and T2DM screening are not re-verified at 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.

Also under Oregon Medicaid: Mounjaro, Ozempic, Wegovy

Zepbound under other plans: Kaiser Permanente Northwest, Regence, Alabama Medicaid, California Medicaid, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid, Illinois Medicaid

All insurance plans · All medications

Summary of Oregon Medicaid's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.