Washington Medicaid coverage for Zepbound (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