Oregon Medicaid coverage for Zepbound (Osa)

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
Diagnosis documented with a code
3 months of a documented diet and exercise program
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

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
To renew, the plan looks for at least 5% reduction in BMI and 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%20Medicaid%20PA%20Criteria%20Guide%20-%20June%201%2C%202026.pdf