Medicaid
Covered (preferred drug)What you need to qualify
- BMI of 30 or higher
- Diagnosed obstructive sleep apnea (AHI of 15 or higher)
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
Initial Approval for OSA
All of:
- Diagnosis of obstructive sleep apnea (OSA) confirmed by sleep study with AHI > 15 events/hour
- BMI > 30 kg/m2
- Has been prescribed CPAP therapy
- Has received counseling on chronic weight management (increased physical activity and reduced calorie diet) and will continue to follow a treatment plan
- Does not have T2DM
- Does not have NYHA Class IV Heart Failure
- Has not had a serious cardiac event in the previous 3 months (acute MI, stroke, unstable angina, or hospitalization due to heart failure)
Reapproval/Continuation for OSA
All of:
- Patient continues to follow a reduced calorie diet and increased physical activity plan
Plus any one of:
- Documented weight loss of >5% of baseline body weight
- Continued maintenance of initial 5% weight loss
Documentation to bring
- Sleep study results demonstrating AHI > 15 events per hour
- Documentation of BMI > 30 kg/m2
- Documentation of CPAP therapy prescription
- Documentation of weight management counseling (increased physical activity and reduced calorie diet)
- Confirmation that patient does not have T2DM
- Confirmation that patient does not have NYHA Class IV Heart Failure
- Confirmation of no serious cardiac event (acute MI, stroke, unstable angina, or heart failure hospitalization) in the previous 3 months
- For reapproval: documentation of >5% body weight loss from baseline or maintenance of initial 5% weight loss
Approval and renewal
- Initial approval: 6 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Patient must continue to follow a reduced calorie diet and increased physical activity plan AND show documented weight loss of >5% of baseline body weight OR continued maintenance of initial 5% weight loss. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- T2DM (type 2 diabetes mellitus)
- NYHA Class IV Heart Failure
- Serious cardiac event in the previous 3 months (acute MI, stroke, unstable angina, or hospitalization due to heart failure)
Policy note: Zepbound is listed as a Preferred Agent for OSA (preferred after clinical criteria are met), though PA is still required based on context. The AHI threshold is >15 events/hour. CPAP must be prescribed but no trial duration is specified — the policy does not explicitly require prior CPAP failure. T2DM patients are explicitly excluded from this OSA indication. The document appears to reference a state Medicaid formulary (possible reference to vtmedicaid.com in the oncology section).
Policy effective April 17, 2026 · verified June 4, 2026 · source: Vermont-PDL-20260417.pdf