Zepbound Medicaid request and fair hearing packet

Your Medicaid coverage

Prior authorization file

• BMI with the date it was measured, and earlier BMI readings
• Weight-related conditions with records: sleep study, A1c trend, blood pressure log, lipid panel
• Diet and exercise program: dates and what it included
• Earlier weight-loss medicines: names, doses, dates and why each stopped
• Any contraindication to a required first-step medicine
• Specialist note, if the state asks for one

Federal rules (U.S. Code and 42 CFR)

• States may exclude or restrict drugs used for weight loss from Medicaid coverage.[1]
• A state prior authorization program must respond within 24 hours of a request.[1]
• Managed-care members have 60 calendar days from the denial notice to request a plan appeal.[2]
• The plan resolves a standard appeal within 30 calendar days, or an expedited one within 72 hours.[3]
• After the plan's decision, the state must allow 90 to 120 days to request a State fair hearing.[3]
• The state ordinarily decides the fair hearing within 90 days.[4]

How two states answer

• Missouri lists Zepbound for obesity at BMI 30 or more, or 27 or more with a weight-related condition, for ages 18 and up.[5]
• California removed Zepbound from its Contract Drugs List on January 1, 2026 and considers requests only for sleep apnea.[6]

Decisions, appeals and hearing dates

Questions for the plan or state

1. Is the denial a benefit exclusion or a missing-criteria decision?
2. Which criteria document did the reviewer use, and what does it require?
3. Can I ask for an expedited appeal, and who decides if it qualifies?
4. Where and how do I request a State fair hearing, and by what date?
5. Will Zepbound continue while the appeal is pending?