Does Washington Medicaid cover Zepbound?

Quick answer · Weight Loss

Washington Medicaid does not cover it for weight loss on Medicaid.

The card and program names below are mapped to Washington 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 May 1, 2025. Source: tirzepatide.pdf. How we verify this data.

Card and program names on file in Washington

Select a name to read the Washington 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

Not covered

Tirzepatide (Zepbound®) is not covered by Apple Health for weight loss in accordance with WAC 182-530-2100(1)(b)(i) and SEC. 1927 [42 U.S.C. 1396r–8](d)(2)(A).

Policy note: Explicitly excluded from coverage for the weight loss indication under Washington State Medicaid (Apple Health) per WAC 182-530-2100(1)(b)(i) and federal Medicaid drug exclusion statute 42 U.S.C. 1396r–8(d)(2)(A).

Policy effective May 1, 2025 · verified June 4, 2026 · source: tirzepatide.pdf

Zepbound for Osa

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • A1C no higher than 6.5%
  • 6 months of a documented diet and exercise program
  • 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 with obesity

All of:

  • Patient is ≥18 years of age
  • Patient does not have diabetes and does not have HbA1C >6.5%
  • Provider attestation that patient has moderate to severe OSA defined as AHI or RDI ≥15 obstructive respiratory events per hour (apneas, hypopneas, or RERAs), without the use of a PAP device
  • Patient meets one of the PAP criteria (consulted and declined PAP, unable to tolerate PAP, or actively using PAP and will continue to use PAP)
  • Patient is engaged in lifestyle interventions including diet, exercise, and behavioral modification
  • Tirzepatide will not be used in combination with another GLP-1 agonist
  • Patient has a BMI >30 kg/m²

Plus any one of:

  • Patient was consulted about PAP use and declined
  • Patient is unable to tolerate PAP therapy
  • Patient is actively using PAP and will continue to use PAP

Reauthorization

All of:

  • Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
  • Patient continues to meet initial criteria 1–6 (age, no diabetes/A1C, OSA attestation, PAP status, lifestyle interventions, no combination GLP-1)
  • Documentation of positive clinical response (e.g., weight loss, fewer AHIs per hour, or improved systolic blood pressure)

Documentation to bring

  • Provider attestation of moderate to severe OSA with AHI or RDI ≥15 obstructive respiratory events per hour
  • Documentation that patient does not have diabetes and HbA1C is ≤6.5%
  • Documentation of BMI >30 kg/m²
  • Documentation of PAP consultation and outcome (declined, unable to tolerate, or actively using PAP)
  • Documentation of patient engagement in lifestyle interventions (diet, exercise, behavioral modification)
  • Confirmation that tirzepatide will not be used in combination with another GLP-1 agonist
  • For reauthorization: documentation of positive clinical response (weight loss, AHI reduction, or improved systolic blood pressure)

Quantity limits

  • 2.5mg/0.5mL, 5mg/0.5mL, 7.5mg/0.5mL, 10mg/0.5mL, 12.5mg/0.5mL, 15mg/0.5mL

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for Documentation of positive clinical response required, such as weight loss, fewer AHIs per hour of sleep, or improved systolic blood pressure. Criteria 1–6 from initial approval must continue to be met (age ≥18, no diabetes/A1C ≤6.5%, provider attestation of moderate-to-severe OSA with AHI/RDI ≥15, PAP consultation/status, lifestyle interventions, and no combination GLP-1 use). BMI criterion (>30 kg/m²) is not explicitly listed among the re-checked criteria at reauthorization.

Not covered when

  • Type 2 diabetes mellitus (patients with T2DM should request GLP-1 indicated for T2DM under policy 27.17.00)
  • HbA1C >6.5%
  • Concurrent use with another GLP-1 agonist
  • Type 1 diabetes

Policy note: This is a Washington State Apple Health (Medicaid) policy. Zepbound is listed as non-preferred; a trial/failure or documented intolerance (severe adverse response) to ONE preferred agent on the Apple Health Preferred Drug List (AHPDL) is required per the class note. Quantity limits list all pen strengths (2.5–15 mg) as approved forms but specific per-fill quantity limits (pens per fill) are not stated in the document. OSA is defined by AHI or RDI ≥15; the PAP criteria are structured as: (a) consulted about PAP AND (b) declined OR (c) unable to tolerate, OR (d) actively using PAP and will continue. Maximum weekly dose is 15 mg once weekly. New FDA indications not listed will be determined case-by-case. Clinical reviewer retains discretion to approve on a case-by-case basis even if all criteria are not met, and may apply reauthorization criteria for patients transitioning from another health plan.

Policy effective May 1, 2025 · verified June 4, 2026 · source: tirzepatide.pdf

Full Washington Medicaid coverage page for Zepbound

Other medications under Washington 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.