Medicaid
Covered (preferred drug)What you need to qualify
- Age 18 and older
- BMI of 30 or higher
- 6 months of a documented diet and exercise program
- Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
Qualification pathways
You can qualify through any one of these.
Initial approval for Obstructive Sleep Apnea
All of:
- Patient is 18 years of age or older
- Diagnosis of moderate to severe Obstructive Sleep Apnea
- Hypersomnolence secondary to another sleep disorder, neurologic disorder, medical condition, or medicine/substance use has been ruled out
- Initial BMI >= 30 kg/m2 documented in medical records
- Respiratory events >= 15 per hour of sleep confirmed by sleep study
- Trial and failure of CPAP or BiPAP device with minimum 3-month duration with documented compliance, unless contraindicated
- Prescriber attests patient is participating in complementary nutritional and lifestyle changes
- Will not be used concomitantly with DPP-4 inhibitors
- Will not be co-administered with another GLP-1 receptor agonist
- No personal or immediate family history of medullary thyroid carcinoma or MEN2
Documentation to bring
- Medical records (e.g., chart notes) documenting diagnosis of moderate to severe OSA
- Sleep study results confirming >= 15 respiratory events per hour of sleep (AHI >= 15)
- Medical records (e.g., chart notes) documenting initial BMI >= 30 kg/m2
- Documentation ruling out hypersomnolence secondary to another sleep disorder, neurologic disorder, medical condition, or substance/medicine use
- Documentation of CPAP or BiPAP trial failure with minimum 3-month duration and documented compliance, or documentation of contraindication to PAP therapy
- Prescriber attestation that patient is participating in complementary nutritional and lifestyle changes
- Documentation that patient has no personal or immediate family history of medullary thyroid carcinoma or MEN2
Quantity limits
- 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — 4 injectors
Approval and renewal
- To renew, the plan looks for Positive clinical response required: decrease in number of apneas and hypopneas during sleep from baseline. Lifestyle attestation IS re-verified at renewal. DPP-4 inhibitor exclusion and GLP-1 co-administration exclusion re-verified at renewal. CPAP/BiPAP trial requirement is not explicitly re-verified at renewal.
Not covered when
- Personal or immediate family history of medullary thyroid carcinoma or MEN2
- Concomitant use of DPP-4 inhibitors
- Co-administration with another GLP-1 receptor agonist
- Hypersomnolence attributable to another sleep disorder, neurologic disorder, medical condition, or medicine/substance use (must be ruled out)
Policy note: Moderate to severe OSA defined as >= 15 respiratory events per hour confirmed by sleep study (AHI >= 15). CPAP or BiPAP trial required for minimum 3 months with documented compliance unless contraindicated. Renewal requires documentation of decreased apneas and hypopneas from baseline plus lifestyle attestation re-verification. Quantity limit is 4 injectors per 28 days.
Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf