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Key takeaways
Most state Medicaid programs won’t directly cover Zepbound for the treatment of obesity unless the beneficiary has obstructive sleep apnea (OSA) in addition to obesity.
If Medicaid plans deny a Zepbound prescription, you and your healthcare provider can appeal through processes like prior authorization and step therapy.
If Medicaid continues to deny coverage for Zepbound and you have to pay for the injectable medicine out of pocket, you can use a prescription discount card to save on the retail price.
Zepbound (generic name: tirzepatide) is a weekly injectable medication approved by the U.S. Food and Drug Administration (FDA) for weight loss management and the treatment of moderate to severe obstructive sleep apnea (OSA) in individuals with obesity. The dual GIP and GLP-1 receptor agonist, manufactured by Eli Lilly, is not uniformly covered by Medicaid; however, some states may provide coverage for the weight loss drug for obesity treatment if deemed medically necessary.
Does Medicaid cover Zepbound?
According to Annie DePasquale, MD, a board-certified family medicine physician and founder and CEO of Collaborating Docs in Arlington, Virginia, coverage for Zepbound varies by state and plan. “Many Medicaid programs now cover at least some anti-obesity medications—but rules vary widely,” she explains. “Some states/plans include Zepbound (often with prior authorization); others still exclude weight-loss drugs or limit coverage to certain clinical scenarios.”
Zepbound’s manufacturer states that some Medicaid plans may cover the prescription medication only for obstructive sleep apnea, but not for chronic weight management or weight loss.
Under the Medicaid Drug Rebate Program (MDRP), state Medicaid programs must cover almost all FDA-approved drugs for medically accepted indications—but weight loss medications like Zepbound, Ozempic, Wegovy, and others are included in a small group of drugs that can be excluded from coverage. Although the FDA has approved six drugs for weight management (IMCIVREE, Saxenda, Wegovy, Qsymia, Xenical, and Zepbound), state Medicaid programs aren’t required to provide coverage for this medical indication.
You can visit the drug manufacturer’s insurance coverage and savings page, scroll down to “I have insurance through Medicaid,” and then use the locator to find your state program’s drug list (PDL) or formulary to see if they cover Zepbound.
Obstructive sleep apnea (OSA)
As mentioned, most Medicaid programs will cover Zepbound for obstructive sleep apnea (OSA). In 2024, the FDA approved the use of Zepbound for OSA in adults with obesity. Because of this, while Medicaid won’t directly cover the medication for weight loss, many state programs will cover beneficiaries diagnosed with the sleep condition who may also be obese.
For example, in Alabama Medicaid’s preferred drug list, Zepbound is preferred for patients with OSA with obesity indication, but not for weight loss directly.
Dr. DePasquale also lists the following as situations where Medicaid may not cover Zepbound:
- Plan excludes anti-obesity meds entirely
- Patient doesn’t meet prior authorization criteria (e.g., body mass index/comorbidity thresholds, recent participation in a structured lifestyle program)
- Contraindications (e.g., history of medullary thyroid carcinoma, multiple endocrine neoplasia Type 2, pregnancy, and lactation)
- Quantity or age limits
How to get approved for Zepbound
If your healthcare provider thinks Zepbound is the best medication to help with weight management, there are a few things you can do together to increase the chances of your Medicaid plan approving it for weight loss.
Prior authorization
Prior authorization, also known as prior approval, pre-authorization, or pre-certification, is a standard health insurance process that helps insurers ensure that the prescribed treatments are medically necessary for beneficiaries. In most cases, your healthcare provider who wants to prescribe Zepbound is responsible for starting the prior authorization request by submitting a medical necessity letter. This request may happen before or after the prescription is sent to your pharmacy, but before the pharmacy fills and dispenses the prescription to you.
According to Dr. DePasquale, this letter typically must include:
- Diagnosis codes
- Body mass index (BMI) and weight trend
- Comorbidities
- Relevant labs and vitals
- Documentation of failed or insufficient response to lifestyle therapy and any prior weight-loss medications
- Current medications
- Risk profiles (e.g., OSA, prediabetes, diabetes, non-alcoholic fatty liver disease, and how weight loss will change outcomes)
Your Medicaid program or managed Medicaid plan will inform the prescriber if any additional information is needed.
Step therapy
Step therapy, also known as “fail first,” or step protocol, is a process in which insurers require you and your healthcare provider to take specific steps before they’ll cover or pay for your medication. You may have to try alternative, lower-cost medications to treat your medical conditions before moving to a more expensive drug like Zepbound. Step therapy for Zepbound could involve a trial of a formulary anti-obesity drug, such as naltrexone/bupropion (brand names Revia/Wellbutrin) or phentermine/topiramate (brand names Adipex/Topamax), as long as they’re not contraindicated or clinically inappropriate, Dr. DePasquale says.
A potential downside to step therapy is that by requiring you to try less expensive drugs, it may disrupt your care, especially if your healthcare provider recommends a medication like Zepbound that isn’t the insurer’s preferred treatment. In these instances, protections should be put in place to ensure the step therapy process doesn’t interfere with your access to the proper treatment.
If approved through prior authorization or after completing step therapy, your healthcare provider can proceed with prescribing Zepbound, and you can then collect it from your pharmacy. “If denied, appeal with any missing documentation (sleep study, cardiometabolic risk notes, dietitian visits),” Dr. DePasquale says. “Ask the plan for a peer-to-peer review if available.”
A peer-to-peer (P2P) review in insurance is a telephone call between a healthcare provider and an insurance company physician to discuss a claim or prior authorization that has been denied or will be denied for medical necessity reasons. The goal of this meeting is for the prescribing provider to justify their request to their peer to get approval for the patient’s drug or medical service.
If this and other processes fail, it may be time to consider other options for covering the drug outside of your Medicaid coverage, or talk to your doctor about alternative options for treatment.
How much does Zepbound cost?
If Medicaid does not approve your healthcare provider’s requested prescription for Zepbound, you may need to pay for the weight loss drug out of pocket. Without insurance, the average retail price of Zepbound is about $1,535 per 4, 5 mg/0.5 mL pens.
RELATED: Does Aetna cover Zepbound?
If your insurance plan approves Zepbound, copays or coinsurance will vary depending on your state’s Medicaid program. “Patients should defer to their treating clinician and, when applicable, their plan’s care manager for the most up-to-date guidance,” Dr. DePasquale says.
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How to save on Zepbound
If your Medicaid program does not approve Zepbound and you find yourself paying out of pocket, there are other ways to save money on it and similar weight loss drugs.
One method to reduce your costs is to visit the prescription medication’s coupon page on SingleCare to obtain it at a discounted price of $950 for 4, 5 mg/0.5 mL pens. SingleCare works with several major pharmacies to provide access to over 10,000 medications at up to an 80% discount off the retail price.
To get started, you’ll want to visit Zepbound’s coupon page and choose the best coupon for you at your preferred pharmacy. From there, you’ll have the option to print your coupon or download it to your mobile device. You’ll show the coupon card to your pharmacist to get your discount on Zepbound injections.
In Dr. DePasquale’s experience, she has seen her Medicaid patients pay out-of-pocket for medications like Zepbound and has witnessed how a combination of medical treatment and lifestyle changes has led to weight loss and significant improvements in blood pressure and blood sugar levels. However, health insurance coverage can be a hindrance to these health outcomes.
“Medications can be a powerful accelerator for the right patient, but access and coverage are often the real gatekeepers, “ she says.
- Savings card, costs, and coverage, Zepbound
- Medicaid.gov, Medicaid Drug Rebate Program (2025)
- Prescription medications to treat overweight & obesity, National Institute of Diabetes and Digestive and Kidney Diseases (2024)
- FDA approves first medication for obstructive sleep apnea, U.S. Food and Drug Administration (2024)
- Alabama Medicaid Agency preferred drug list, Alabama Medicaid (2025)
- Insurance denials: A peer-to-peer problem in neonatology, Journal of Perinatology (2024)
- Annie DePasquale, MD, Collaborating Docs