Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (dyslipidemia, HTN, OSA, T2DM, and CVD)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Pathway 1: BMI >= 30
All of:
- Member is 18 years of age or older
- BMI >= 30
- Not pregnant or nursing
- No history of eating disorder (anorexia, bulimia, binge eating disorder)
- Prescriber evaluated and determined no medical or medication contraindications
- Member has participated in a weight loss treatment plan in the past 6 months and will continue
Pathway 2: BMI 27-<30 with comorbidities
All of:
- Member is 18 years of age or older
- BMI >= 27 and < 30
- Not pregnant or nursing
- No history of eating disorder (anorexia, bulimia, binge eating disorder)
- Prescriber evaluated and determined no medical or medication contraindications
- Member has participated in a weight loss treatment plan in the past 6 months and will continue
Plus any one of:
- Currently being treated for dyslipidemia AND at least one other qualifying risk factor
- Currently being treated for hypertension AND at least one other qualifying risk factor
- Currently being treated for sleep apnea AND at least one other qualifying risk factor
- Currently being treated for type 2 diabetes mellitus AND at least one other qualifying risk factor
- Has cardiovascular disease (history of MI, coronary revascularization, angina pectoris, stroke, intermittent claudication with ABI <= 0.9, peripheral arterial revascularization due to atherosclerotic disease, or amputation due to atherosclerotic disease) AND at least one other qualifying risk factor
Documentation to bring
- Completed, signed, and dated Prior Authorization Drug Attachment for Anti-Obesity Drugs form (F-00163)
- Documentation of member's current BMI
- Documentation of qualifying comorbidities (if BMI 27-<30 pathway)
- Documentation that member has participated in a weight loss treatment plan in the past 6 months
- Prescriber attestation of no medical or medication contraindications
- Confirmation member is not pregnant or nursing
- Confirmation no history of eating disorder
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Member must achieve at least 5% weight loss from baseline. Member must be taking an appropriate maintenance dose as outlined in Zepbound prescribing information. PA will not be renewed if BMI falls below 24. Maximum treatment period is 12 continuous months; after that, member must wait 6 months before requesting again. ForwardHealth allows only two lifetime weight loss attempts with Zepbound. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Nursing (breastfeeding)
- History of eating disorder (anorexia, bulimia, binge eating disorder)
- Medical or medication contraindications as determined by prescriber
- BMI below 24 at renewal — PA will not be renewed
- Only one anti-obesity drug covered per member at a time
- Maximum of two lifetime weight loss attempts with Zepbound
- After 12 months of continuous treatment, must wait 6 months before requesting again
- Pregnancy
Policy note: ForwardHealth (Wisconsin Medicaid). The document does not specify a pediatric BMI percentile threshold for Zepbound (only Wegovy/orlistat/phentermine-topiramate/Xenical are listed for the pediatric 95th percentile rule), and the general anti-obesity criteria specify age 18+ for the BMI 27-<30 pathway. Dual eligibles enrolled in Medicare Part D PDP are also covered for anti-obesity drugs.
verified June 3, 2026 · source: Pa policy