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, dyslipidemia, T2DM, coronary_heart_disease, MASH, and OSA)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Initial Approval — BMI > 30
All of:
- Age >= 18 years
- Treatment is for management of obesity
- BMI > 30 kg/m² (documented via medical records/chart notes)
- Prescriber attests patient is participating in complementary nutritional and lifestyle changes
- Medication will not be used in combination with other FDA-approved obesity/weight loss medications
- Will not be co-administered with another GLP-1 receptor agonist
- No personal or immediate family history of medullary thyroid carcinoma or MEN2
Initial Approval — BMI > 27 with comorbidity
All of:
- Age >= 18 years
- Treatment is for management of obesity
- BMI > 27 kg/m² (documented via medical records/chart notes)
- Prescriber attests patient is participating in complementary nutritional and lifestyle changes
- Medication will not be used in combination with other FDA-approved obesity/weight loss medications
- Will not be co-administered with another GLP-1 receptor agonist
- No personal or immediate family history of medullary thyroid carcinoma or MEN2
Plus any one of:
- Hypertension
- Dyslipidemia
- Diabetes
- Coronary heart disease
- MASH/NASH
- Obstructive sleep apnea
Renewal
All of:
- Continued participation in complementary nutritional and lifestyle changes
- Medication will not be used in combination with other obesity/weight loss medications
- Documentation of >= 5% weight loss from baseline body weight
Documentation to bring
- Medical records (e.g., chart notes) documenting BMI > 30 kg/m² (BMI-only pathway)
- Medical records (e.g., chart notes) documenting BMI > 27 kg/m² with a weight-related comorbidity (comorbidity pathway)
- Prescriber attestation that patient is participating in complementary nutritional and lifestyle changes
- At renewal: medical records (e.g., chart notes) documenting weight loss of >= 5% of baseline body weight
Quantity limits
- all strengths — 4 injections/month
Approval and renewal
- To renew, the plan looks for at least 5% weight loss from the starting weight and Documentation of >= 5% weight loss from baseline body weight. Continued participation in complementary nutritional and lifestyle changes required. Patients not meeting renewal criteria may be approved for up to one month to allow for titration off medication. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Personal or immediate family history of medullary thyroid carcinoma (MTC)
- Personal or immediate family history of multiple endocrine neoplasia type 2 (MEN2)
- Concurrent use of other FDA-approved obesity/weight loss medications
- Concurrent use of another GLP-1 receptor agonist
Policy note: PDL Status: Preferred (P). Document is TennCare PDL (Tennessee Medicaid). No pediatric pathway exists for Zepbound (age minimum is 18). Patients not meeting renewal criteria may be approved for up to one month to allow for titration off medication. The lifestyle program attestation is required (prescriber-attested participation), not merely FDA label language — set requires_lifestyle_program: true. The document does not specify separate quantity limits by dose strength; a single limit of 4 injections/month applies to all strengths. The Zepbound OSA indication is not addressed in this document (only weight_loss criteria are presented here).
Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf