What BMI do you need for Zepbound under Priority Health?

For weight loss on Medicaid plans, Priority Health requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.

How long does a Zepbound approval last with Priority Health?

Initial approvals last 6 months, and renewals are granted in 6-month periods.

What does Priority Health require to renew Zepbound?

At least 5% weight loss from the starting weight and Adults (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy.

How current is this information?

This page reflects Priority Health's written policy as of May 1, 2025, last verified against the source document on June 10, 2026.

Does Priority Health cover Zepbound?

Zepbound for Weight Loss

What Priority Health requires, by plan type. Open this indication on its own page →

Medicaid

Covered (preferred drug)

What you need to qualify

Age 18 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (HTN, coronary_artery_disease, T2DM, dyslipidemia, and OSA)

Qualification pathways

You can qualify through any one of these.

Adult (age >= 18): Obesity

All of:

Patient age >= 18 years
Prescriber attests patient will not use more than one weight loss medication concurrently
Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
Prescriber attests medication is part of a total treatment plan including diet and exercise
Prescriber attests patient has been informed weight may return with cessation of medication
Initial BMI >= 30 kg/m2

Adult (age >= 18): Overweight with comorbidity

All of:

Patient age >= 18 years
Prescriber attests patient will not use more than one weight loss medication concurrently
Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
Prescriber attests medication is part of a total treatment plan including diet and exercise
Prescriber attests patient has been informed weight may return with cessation of medication
Initial BMI >= 27 kg/m2 and < 30 kg/m2

Plus any one of:

Hypertension
Coronary artery disease
Diabetes
Dyslipidemia
Sleep apnea

Documentation to bring

Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist (Wegovy, Saxenda, or Zepbound) concurrently with a DPP4 inhibitor
Documentation of patient age >= 18 years
Documentation of baseline BMI >= 30 kg/m2, OR >= 27 kg/m2 with qualifying comorbidity
If eating disorder present: prescriber attestation that treatment has been optimized and confirms safety and appropriateness
Prescriber attestation that metabolic or other reasons for obesity have been ruled out or diagnosed and treated
Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
Prescriber attestation that medication is part of a total treatment plan including diet and exercise
Prescriber attestation that patient has been informed weight may return with cessation of medication
For renewal: clinical documentation of weight loss >= 5% from baseline

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Adults (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Lactation
Personal or family history of medullary thyroid cancer
Personal or family history of multiple endocrine neoplasia type II
Concurrent use of more than one weight loss medication in this drug class
Concurrent use with DPP4 inhibitor
Age < 18 years (Zepbound is restricted to age >= 18 per this policy)
Pregnancy

Policy note: Document lists Zepbound with a registered trademark symbol (Zepbound®). Minimum age for Zepbound is 18 per this policy (document states 'Patient age >=18 years (benzphetamine, diethylpropion, phendimetrazine, Zepbound®)'). No pediatric criteria apply to Zepbound. Duration of approval is 6 months for both initial and renewal. MDHHS recommends prescribers consider the benefits of a diabetes prevention program for their patients.

Policy effective May 1, 2025 · verified June 10, 2026 · source: medicaid-rx-pa-criteria.pdf

Why Zepbound requests get denied by Priority Health

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.
BMI not documented in the chart notes (or documented without a baseline weight and date).
Qualifying weight-related condition not documented with its own diagnosis code.
Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Priority Health cover Zepbound?: Priority Health covers Zepbound for weight loss with prior authorization on Medicaid.
What BMI do you need for Zepbound under Priority Health?: For weight loss on Medicaid plans, Priority Health requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.
How long does a Zepbound approval last with Priority Health?: Initial approvals last 6 months, and renewals are granted in 6-month periods.
What does Priority Health require to renew Zepbound?: At least 5% weight loss from the starting weight and Adults (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy.
How current is this information?: This page reflects Priority Health's written policy as of May 1, 2025, last verified against the source document on June 10, 2026.