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Zepbound (tirzepatide) — Coverage Criteria for Obstructive Sleep Apnea
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Defines UnitedHealthcare prior authorization requirements for coverage of Zepbound (tirzepatide) when prescribed for obstructive sleep apnea (OSA) in adults with obesity; applies to members subject to the payer's pharmacy clinical programs and state mandates.
Removed requirement for symptoms of OSA.
Removed requirement to not have significant craniofacial abnormalities.
Added description of mixed and central apneas.
Coverage Criteria for Zepbound (tirzepatide)
Initial Authorization
Covered when ALL of the following are met
Authorization will be issued for 6 months
Reauthorization
Reauthorization is approved when ALL of the following are met (with branching based on duration on therapy)
Authorization length: 6 months for <52 weeks on therapy; 12 months for >=52 weeks on therapy
Patients with a diagnosis of predominant central or mixed sleep apnea are excluded from coverage. The policy defines this as when the percent of mixed or central apneas/hypopneas is > 50% of all respiratory events. Prescribers must attest that the patient does not have predominant central or mixed sleep apnea as part of the authorization documentation.
Use of Zepbound solely for weight loss is typically a benefit exclusion under the payer's programs. Coverage of Zepbound through this policy is limited to the approved obstructive sleep apnea (OSA) indication in adults with obesity; the program specifically allows coverage for Zepbound when prescribed for OSA rather than for general chronic weight management.
Key Clinical Thresholds and Codes
Initial Therapy Requirements
Initial therapy
Initial authorization criteria
Authorization will be issued for 6 months
Continuation and Reauthorization Requirements
Continuation/Reauthorization
Reauthorization rules depend on duration of prior continuous therapy and demonstrated response.
Provider Responsibilities and Documentation
Prior Authorization Required
Prior authorization is required for Zepbound (tirzepatide) when requested for obstructive sleep apnea. Approval will be granted only when the member meets all clinical criteria outlined in the policy (age, BMI, documented moderate-to-severe OSA, prior weight-loss attempt(s), PAP adherence or ineligibility, concomitant lifestyle intervention, absence of diabetes, and required prescriber specialty/attestations). Authorization duration: 6 months.
- Policy number: 2025 P 1475-2
- Effective date: 2026-03-01
- Approval duration: 6 months
Potential Supply Limits
Supply limits may apply. Providers should be aware that quantity or duration limits could be enforced at the plan or pharmacy level and may affect dispensing.
- Check member-specific benefit and pharmacy limits prior to prescribing
- Supply/quantity limits subject to change per plan formulary rules
Required Documentation
Complete clinical documentation must be submitted with the prior authorization request to support medical necessity. Incomplete documentation may delay review or result in denial.
- Required records: recent sleep study report showing AHI, REI, or RDI and the numeric value
- Documentation of BMI ≥ 30 kg/m2
- Evidence of at least one prior unsuccessful dietary weight-loss attempt
- Documentation of PAP therapy adherence (≥4 hours/night for ≥70% of nights) or reason patient is not a candidate for PAP
- Attestation that therapy will be used with reduced-calorie diet and increased physical activity
- Attestation that patient does not have diabetes (HgA1c ≤ 6.5%)
- Provider attestations that patient was counseled on positional therapy and avoidance of alcohol/sedatives before bedtime
- Attestation that patient has no planned surgery for sleep apnea or obesity and does not have predominant central/mixed sleep apnea (>50% central/mixed events)
- Prescriber is the sleep specialist or documentation of consultation with a sleep specialist
Denial Triggers
Requests will be denied if required criteria or documentation are missing or if clinical thresholds are not met.
- Denial triggers include: missing sleep study or numeric AHI/REI/RDI values, BMI < 30 kg/m2, no record of prior weight-loss effort, lack of PAP adherence data when indicated, HbA1c > 6.5% or diagnosis of diabetes, absence of required attestations, prescriber not a sleep specialist (or no consultation documented)
- Incomplete or absent medical records may result in denial or request for additional information
Background and Therapeutic Context
Zepbound (tirzepatide) is a combined glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist. It is indicated for treatment of moderate-to-severe obstructive sleep apnea (OSA) in adults with obesity, and is also indicated for chronic weight management in adults with obesity or overweight with at least one weight-related comorbidity. Although weight-loss medications are typically a benefit exclusion, this policy permits coverage of Zepbound specifically when used for the OSA indication in adults with obesity.
Definitions and Terms
Step Therapy and Supply Constraints
| Item | Limit / Notes |
|---|---|
| Supply limits | |
| Supply limits may be in place. |
Site of Care Considerations
Site of care — no restriction but supply limits possible
Site of care is not explicitly restricted by the policy, but supply limits may be in place that affect dispensing regardless of setting.
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