Virginia Medicaid coverage for Zepbound (Weight Loss)

No additional clinical requirements are listed beyond the diagnosis.

Documentation to bring

• Weight Management Agents SA Form

Policy note: Zepbound is listed as a Non-Preferred agent under the Weight Management Agents CLOSED CLASS. The SA criteria reference a 'Weight Management Agents SA Form' for full clinical criteria details, which are not reproduced in this document. Authorization length is 'as indicated on fax form'. Note: the document states 'The selected GLP-1 Receptor Agonist is injectable brand Wegovy' in the context of the CV risk reduction and likely MASH SA forms, which may mean Zepbound is not the selected agent for those indications.

Policy effective April 1, 2026 · verified June 4, 2026 · source: VAmed-PDL-List-Criteria-20260401-v6.pdf