CurrentCignaPolicy N/A

Zepbound (tirzepatide) drug quantity limits — Per Days

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Defines per-days drug quantity limits and exception criteria for Zepbound (tirzepatide) for Cigna-administered health benefit plans; applies to pharmacy dispensing at retail and home delivery.

Policy Summary

PayerCigna

PolicyZepbound (tirzepatide) drug quantity limits — Per Days

Policy CodePolicy N/A

Change TypeQuantity limits revised, clarified, and added

Effective Date

Last ReviewJul 16, 2025

Next Review DateJul 17, 2024

Key ActionLimit dispensing to retail maximum 2 mL (4 pens or vials) per 28 days and home delivery maximum 6 mL (12 pens or vials) per 84 days.

SourceLink

POLICY UPDATE CHANGES

Quantity limits for multiple Zepbound strengths were changed to 2 mL (4 pens or vials) per 28 days at retail and 6 mL (12 pens or vials) per 84 days at home delivery.

Quantity limits for 2.5 mg pens and vials were clarified to accumulate across both dosage forms.

New quantity limits were added for multiple vial strengths (including 5, 7.5, 10, 12.5, 15 mg) at retail and home delivery.

Override criteria were removed for updated quantity limits; no clinical overrides apply.

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CurrentCignaPolicy N/A

Zepbound (tirzepatide) drug quantity limits — Per Days

Customize your policy alerts

Sign up for all Cigna policy alerts

Know when Cigna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines per-days drug quantity limits and exception criteria for Zepbound (tirzepatide) for Cigna-administered health benefit plans; applies to pharmacy dispensing at retail and home delivery.

Policy Summary

PayerCigna

PolicyZepbound (tirzepatide) drug quantity limits — Per Days

Policy CodePolicy N/A

Change TypeQuantity limits revised, clarified, and added

Effective Date

Last ReviewJul 16, 2025

Next Review DateJul 17, 2024

Key ActionLimit dispensing to retail maximum 2 mL (4 pens or vials) per 28 days and home delivery maximum 6 mL (12 pens or vials) per 84 days.

SourceLink

POLICY UPDATE CHANGES

Quantity limits for multiple Zepbound strengths were changed to 2 mL (4 pens or vials) per 28 days at retail and 6 mL (12 pens or vials) per 84 days at home delivery.

Quantity limits for 2.5 mg pens and vials were clarified to accumulate across both dosage forms.

New quantity limits were added for multiple vial strengths (including 5, 7.5, 10, 12.5, 15 mg) at retail and home delivery.

Override criteria were removed for updated quantity limits; no clinical overrides apply.

Coverage Criteria

Quantity limits and exceptions

Covered when the following per‑days quantity limits are not exceeded; certain limited exceptions may be allowed as medically necessary when criteria are met.

Per‑days quantity limits: For each listed Zepbound strength and formulation, dispensing is limited to a retail maximum of 2 mL (4 pens or vials) per 28 days and a home delivery maximum of 6 mL (12 pens or vials) per 84 days.retail=2 mL/28 days; home=6 mL/84 days

Limits apply across pens and vials where specified.

Exceptions: A one‑time exception for additional quantity may be allowed as medically necessary only when the specific exception criteria in this policy are met; any other exception is considered not medically necessary.one‑time override possible when documented criteria met

No clinical overrides apply to the Per Days quantity limits except as explicitly stated.

Any request for an exception to the stated quantity limits that does not meet the specific exception criteria detailed in this policy is considered not medically necessary.

Requests that exceed the specified per‑days dispensing limits for Zepbound without meeting the policy’s explicit one‑time exception criteria are not medically necessary; there are no overrides to the Per Days quantity limits except as explicitly described.

Provider Actions and Billing Guidance

Denial Risk

Coding / coverage mismatch — denial risk

Claims submitted for services that are not accompanied by covered diagnosis or procedure code(s) under the applicable coverage policy will be denied as not covered. When billing, providers must use the most appropriate codes as of the date of submission. Review coding carefully to avoid denial for coding/coverage mismatch.

Claims submitted without covered codes will be denied.

Denial Risk

Quantity limit exceedance — denial risk

Zepbound quantity limits are enforced by per‑days thresholds for retail and home delivery. Requests that exceed the per‑days quantity limits shown in this policy will be denied. No clinical overrides apply to these per‑days quantity limits.

Retail maximum = 2 mL (4 pens or vials) per 28 days.
Home Delivery maximum = 6 mL (12 pens or vials) per 84 days.
No clinical overrides to the Per Days quantity limits.

Quantity Limits (Per-Days)

Retail quantity limit — Zepbound

ProductZepbound (tirzepatide) all strengths/formulations (pens and vials)

Retail limit2 mL (4 pens or vials) per 28 days

ApplicabilityApplies across listed pen and vial strengths (2.5, 5, 7.5, 10, 12.5, 15 mg)

Override policyNo clinical overrides to Per Days retail quantity limit except as explicitly stated in policy

Home delivery quantity limit — Zepbound

ProductZepbound (tirzepatide) all strengths/formulations (pens and vials)

Home delivery limit

Step Therapy / Historical Limits

Historic policy element	Action taken
One-claim per 21 days limit for GLP-1 or GLP-1/GIP agonists (collective: one claim for one GLP-1 or GLP-1/GIP agonist every 21 days at retail or home delivery)	Removed from this policy; retained instead in a separate 'Claim Per Days' policy (refer to Weight Loss - Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy - Claim Per Days)

Definitions

Definition / product identifier

Drug name (term)Zepbound (tirzepatide subcutaneous injection)

ClassGLP-1/GIP receptor agonist

Indications (summary)Adjunct to diet and exercise for chronic weight management in adults with overweight plus comorbidity and adults with obesity; treatment of moderate-to-severe OSA in adults with obesity

Available strengths/formsPens and vials including 2.5, 5, 7.5, 10, 12.5, 15 mg strengths as listed in policy

Administration schedule and titration

Dosing frequencyOnce weekly (QW) subcutaneous injection

Initiation and titration

Background

Zepbound (tirzepatide) is a GLP‑1/GIP receptor agonist indicated as an adjunct to a reduced‑calorie diet and increased physical activity for chronic weight management in adults with overweight plus at least one weight‑related comorbidity and for adults with obesity; dosing begins at 2.5 mg subcutaneously once weekly with planned titration to maintenance doses up to a maximum of 15 mg weekly. The policy defines per‑days dispensing limits for all Zepbound strengths and formulations (pens and vials) — including a retail maximum of 2 mL (4 pens or vials) per 28 days and a home delivery maximum of 6 mL (12 pens or vials) per 84 days — and notes that exceptions are limited and only covered as medically necessary when the policy’s specific criteria are met.