Does Michigan Medicaid cover Zepbound?

Quick answer · Weight Loss

Michigan Medicaid covers Zepbound for weight loss with prior authorization on Medicaid.

The card and program names below are mapped to Michigan Medicaid in our records. Coverage depends on the reason for treatment and the requirements in the policy.

Policy last verified June 4, 2026. Policy effective July 1, 2026. Source: MIRx_clinical_criteria.pdf. How we verify this data.

Card and program names on file in Michigan

Select a name to read the Michigan Medicaid policy for Zepbound. These are names we recognize, including older names and spelling variants; this is not a list of plans currently accepting members.

Don't see your card name? Check your card or call the pharmacy-benefit number on your card. If you also have Medicare, confirm which plan handles this prescription.

Zepbound for Weight Loss

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 40 or higher
  • Prior trial of benzphetamine, diethylpropion, orlistat, phendimetrazine, and phentermine

Qualification pathways

You can qualify through any one of these.

Step therapy: allergy, contraindication, DDI, side effects, or trial-and-failure of all five preferred agent types

Plus any one of:

  • Allergy to all five types of preferred medications (benzphetamine, diethylpropion, orlistat, phendimetrazine, phentermine)
  • Contraindication or drug-to-drug interaction with all five types of preferred medications
  • History of unacceptable side effects with all five types of preferred medications
  • Trial and failure with all five types of preferred agents (at least one orlistat agent, one phentermine product, plus benzphetamine, diethylpropion, and phendimetrazine)

Initial approval — additional medication-specific criteria (all required)

All of:

  • Patient age ≥18 years
  • Patient has an initial BMI classified as morbidly obese (BMI ≥40 kg/m²)
  • Prescriber attests patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attests documented failure of all other clinically appropriate weight loss interventions
  • Prescriber attests use of GLP-1 for weight loss is to avert the need for higher-cost bariatric surgery
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
  • Prescriber attests to absence of contraindications including pregnancy, lactation, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type II
  • Prescriber attests medication therapy is part of a total treatment plan including diet and exercise/activity
  • Prescriber attests patient has been informed weight may return with cessation unless lifestyle changes are permanently adopted
  • Prescriber attests metabolic or other reasons for obesity/symptoms have been ruled out or diagnosed and treated (e.g., thyroid dysfunction, diabetes, sleep apnea)
  • For patients with an eating disorder: prescriber attests treatment has been optimized and confirms safety and appropriateness

Documentation to bring

  • Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attestation of documented failure of all other clinically appropriate weight loss interventions
  • Prescriber attestation that use of GLP-1 is to avert the need for higher-cost bariatric surgery
  • Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP-4 inhibitor
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN2)
  • Prescriber attestation that medication is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been informed about weight return upon cessation
  • Prescriber attestation that metabolic or other causes of obesity have been ruled out or treated
  • For patients with eating disorder: prescriber attestation that treatment has been optimized
  • Documentation of step therapy: allergy, contraindication, DDI, unacceptable side effects, or trial-and-failure of all five preferred agent types (benzphetamine, diethylpropion, orlistat, phendimetrazine, phentermine)
  • Baseline BMI documentation (≥40 kg/m²) for patients ≥18 years
  • Renewal — patients ≥18: clinical documentation of weight at renewal showing ≥5% weight loss from baseline

Quantity limits

  • 2.5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 7.5 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 10 mg/0.5 mL pens/vials — 2 mL (4 pens/vials) per 28 days
  • 12.5 mg/0.5 mL pens — 2 mL (4 pens) per 28 days
  • 15 mg/0.5 mL pens — 2 mL (4 pens) per 28 days
  • KwikPen 2.5 mg/dose (10 mg/2.4 mL), KwikPen 5 mg/dose (10 mg/2.4 mL), KwikPen 7.5 mg/dose (10 mg/2.4 mL), KwikPen 10 mg/dose (10 mg/2.4 mL), KwikPen 12.5 mg/dose (10 mg/2.4 mL), KwikPen 15 mg/dose (10 mg/2.4 mL) — 2.4 mL (1 KwikPen) per 28 days

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 For patients ≥18 years: must have maintained weight loss of ≥5% from baseline weight at initiation of therapy. For 1st renewal of established members with initial approval prior to 1/1/2026: prescriber attests to morbid obesity at start, documented failure of all other weight loss interventions, and use was to avert bariatric surgery, plus same weight maintenance requirement. 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 a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, sitagliptin)
  • Concurrent use of another anti-obesity GLP-1 agonist
  • Patients under age 18 (Zepbound minimum age is 18 per this policy)
  • Pregnancy

Policy note: This policy applies to 'non-preferred GLP-1s only' for weight loss under Michigan Medicaid PDL. Zepbound (tirzepatide) minimum age per this policy is 18 years. The morbidly obese BMI threshold for adults is ≥40 kg/m²; the policy does not apply the 12-year minimum or pediatric BMI percentile pathway to Zepbound (only to Wegovy and Saxenda/liraglutide). MDHHS recommends prescribers consider the benefits of a diabetes prevention program. A special 1st renewal pathway exists for established members with initial approval prior to 1/1/2026 requiring attestations of morbid obesity at start, documented failure of other interventions, and use to avert bariatric surgery, plus the standard ≥5% weight loss requirement.

Policy effective July 1, 2026 · verified June 4, 2026 · source: MIRx_clinical_criteria.pdf

Zepbound for Osa

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • Diagnosed obstructive sleep apnea

Qualification pathways

You can qualify through any one of these.

Initial approval for OSA

All of:

  • Patient is >= 18 years of age
  • Initial BMI >= 27 kg/m²
  • Documented diagnosis of moderate to severe obstructive sleep apnea (OSA)
  • Prescriber attests patient will not use Zepbound concurrently with another GLP-1 agonist
  • Prescriber attests patient will not use Zepbound concurrently with a non-GLP-1 weight loss medication
  • Prescriber attests patient will not use Zepbound concurrently with a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
  • For patients with an eating disorder: prescriber attests treatment has been optimized and confirms safety and appropriateness
  • Prescriber attests metabolic or other reasons for obesity/symptoms have been ruled out or diagnosed and treated (e.g., thyroid dysfunction, diabetes)
  • Prescriber attests to absence of contraindications including pregnancy, lactation, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type II
  • Prescriber attests medication therapy is part of a total treatment plan including diet and exercise/activity as appropriate
  • Prescriber attests patient has been informed weight may return with cessation of medication unless healthy lifestyle changes are permanently adopted

Renewal/continuation for OSA

All of:

  • Patient is currently established on Zepbound for moderate to severe OSA
  • Clinical documentation demonstrating >= 5% weight loss from baseline weight at initiation of therapy

Documentation to bring

  • Prescriber attestation that patient will not use Zepbound concurrently with another GLP-1 agonist
  • Prescriber attestation that patient will not use Zepbound concurrently with a non-GLP-1 weight loss medication
  • Prescriber attestation that patient will not use Zepbound concurrently with a DPP-4 inhibitor
  • Documentation of patient age >= 18 years
  • Baseline BMI documentation (>= 27 kg/m²)
  • Documented diagnosis of moderate to severe obstructive sleep apnea (OSA)
  • For patients with eating disorder: prescriber attestation that treatment has been optimized and is safe/appropriate
  • Prescriber attestation that metabolic or other causes of obesity have been ruled out or treated
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal/family history of medullary thyroid cancer or MEN type II)
  • Prescriber attestation that therapy is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been counseled on weight regain risk upon cessation
  • [Renewal] Clinical documentation of current weight showing >= 5% weight loss from baseline

Quantity limits

  • 2.5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 7.5 mg/0.5 mL — 2 mL (4 pens/vials)
  • 10 mg/0.5 mL — 2 mL (4 pens/vials)
  • 12.5 mg/0.5 mL — 2 mL (4 pens)
  • 15 mg/0.5 mL — 2 mL (4 pens)

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 Prescriber must provide clinical documentation showing the patient has maintained a weight loss of >= 5% from baseline weight at initiation of therapy. Patient must be currently established on the medication for the OSA diagnosis. 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
  • Multiple endocrine neoplasia type II (MEN2)
  • Concurrent use of another GLP-1 agonist
  • Concurrent use of a non-GLP-1 weight loss medication
  • Concurrent use of a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, sitagliptin)
  • Pregnancy

Policy note: This is Michigan Medicaid (MDHHS) criteria managed by Prime Therapeutics. The OSA indication requires 'moderate to severe' OSA but no specific AHI threshold is stated. The policy does not require PAP/CPAP therapy trial prior to approval. MDHHS recommends (but does not require) that prescribers consider referring patients to a diabetes prevention program. The 12.5 mg and 15 mg strengths are listed as 'pens' only (no vials option). For renewal, only the 5% weight loss maintenance is required — BMI threshold, OSA diagnosis attestation, and concurrent medication restrictions are not explicitly re-verified at renewal per the stated renewal criteria.

Policy effective July 1, 2026 · verified June 4, 2026 · source: MIRx_clinical_criteria.pdf

Full Michigan Medicaid coverage page for Zepbound

Other medications under Michigan Medicaid

All insurance plans · All medications

This page summarizes written Medicaid policies on file. It is not a guarantee of coverage or medical advice. Confirm your current benefits and prior-authorization requirements with your plan.