Zepbound (tirzepatide) for obstructive sleep apnea
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Policy approves Zepbound for Select Health of South Carolina members with moderate to severe obstructive sleep apnea who meet specified clinical and documentation criteria; affects prescribers and prior authorization reviewers.
Zepbound (tirzepatide) will be approved for Select Health members with moderate to severe obstructive sleep apnea who meet specific criteria.
Initial approvals are for up to 6 months and renewals up to 12 months when criteria are met.
Required documentation includes weight, height, BMI >= 30, confirmation of moderate to severe obstructive sleep apnea, and charted participation in a doctor-directed weight loss program for at least 3 months.
Coverage Criteria for Zepbound (tirzepatide)
inv-01: Initial Therapy
Covered when ALL of the following are met
When met, approve up to 6 months for initial requests.
inv-02: Continuation/Renewal
Covered when ALL of the following are met
When met, approve up to 12 months for renewals.
Requests for Zepbound that do not meet all of the policy’s listed criteria will be referred to a clinical reviewer for medical necessity review and may be denied if criteria are not met. The policy requires documented support in the chart for each approval condition before prior authorization will be granted.
Required documentation must be present in the chart. Missing items — including patient weight and height, documentation that the patient currently has moderate to severe obstructive sleep apnea, a recorded BMI ≥ 30, or evidence the member followed a doctor-directed weight loss program for ≥ 3 months — will result in referral to a clinical reviewer and may lead to denial of the request.
Key Clinical Thresholds
Provider Requirements and Authorization Details
Prior authorization approval durations
Prior authorization is required. When all listed coverage criteria are met, initial approvals are authorized for up to 6 months and renewal approvals for up to 12 months.
Step-therapy / additional provider requirements
No additional step-therapy or substitution requirements are specified in this policy for Zepbound; providers should follow the listed documentation and authorization steps in this notice.
Required chart documentation
Chart notes must include the patient’s weight and height; documentation that the patient currently has moderate to severe obstructive sleep apnea; the patient’s BMI (must be 30 or higher); and evidence the member followed a doctor-directed weight loss program (lower-calorie diet and physical activity) for at least 3 months and still did not lower their BMI below 30.
- Weight and height documented in chart notes
- Confirmation the patient currently has moderate to severe obstructive sleep apnea
- Documented BMI ≥ 30
- Documentation of ≥3 months in a doctor-directed weight loss program (lower-calorie diet and physical activity) with BMI remaining ≥30
Documentation insufficiency — referral or possible denial
Requests that do not include the required chart documentation (weight/height, BMI ≥30, confirmation of moderate to severe OSA, or documentation of ≥3 months of a doctor-directed weight loss program) will be referred to a clinical reviewer for medical necessity review and may be denied.
Definitions
Initial Therapy
inv-13: Initial
Initial approval
Renewal / Continuation
inv-14: Renewal
Renewal approval
Background
This policy establishes coverage for Zepbound (tirzepatide) for Select Health members with moderate to severe obstructive sleep apnea who are obese. Coverage is contingent on documented clinical criteria in the medical record, including a BMI ≥ 30 and prior participation in a physician-directed weight-loss program of at least 3 months. The policy takes effect July 5, 2026.
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