CurrentUnitedHealthcarePolicy 2025 P 1475-2

Zepbound (tirzepatide) — Coverage Criteria for Obstructive Sleep Apnea

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.

Policy Summary

PayerUnitedHealthcare

PolicyZepbound (tirzepatide) — Coverage Criteria for Obstructive Sleep Apnea

Policy CodePolicy 2025 P 1475-2

Change TypeMaterial (criteria removed and added)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with medical records documenting age ≥18, BMI ≥30 kg/m2, sleep study showing AHI/REI/RDI >15, prior weight-loss efforts, counseling, and prescriber specialty.

SourceLink

POLICY UPDATE CHANGES

Removed requirement for symptoms of OSA.

Removed requirement to not have significant craniofacial abnormalities.

Added description of mixed and central apneas.

6 monthsinitial authorization duration

12 monthsreauthorization duration (≥52 wks)

≥30BMI threshold

>15 AHIOSA severity threshold

≥10%

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Coverage Criteria for Zepbound (tirzepatide)

Initial Authorization

Covered when ALL of the following are met

Initial Authorization: Treatment is requested for obstructive sleep apnea; patient is 18 years of age or older; submission of medical records documenting all of the following: BMI ≥ 30 kg/m2; moderate-to-severe obstructive sleep apnea evidenced by a sleep study with either AHI > 15 events/hour, REI > 15 events/hour, or RDI > 15 events/hour; at least one previous unsuccessful dietary effort to lose weight; either continued symptoms of OSA despite adherence to positive airway pressure (PAP) therapy (adherence defined as ≥ 4 hours/night for ≥ 70% of nights) OR patient is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities); used in combination with a reduced calorie diet and increased physical activity; patient does not have a diagnosis of diabetes or HgA1c > 6.5%; provider attests patient was counseled on appropriate positional therapy and avoidance of alcohol and/or sedatives before bedtime; prescriber attests the patient does not have planned surgery for sleep apnea or obesity and does not have a diagnosis of predominant central or mixed sleep apnea (>50% central/mixed events); prescribed by or in consultation with a sleep specialist

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)

Duration branching: Either: (1) patient has been on Zepbound for less than 52 weeks of consecutive therapy; OR (2) patient has been on Zepbound for greater than or equal to 52 weeks of consecutive therapy and submission of medical records confirms a 50% decrease from baseline after initiation of Zepbound in one of the following indices: AHI, RDI, or REI

Additional reauth requirements: Patient has had a weight loss of ≥ 10% of baseline body weight; used in combination with a reduced calorie diet and increased physical activity; patient does not have a diagnosis of diabetes or HgA1c > 6.5%; patient continues to require treatment for obstructive sleep apnea

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

inv-06: Sleep study indices

Sleep study severityAHI, REI, or RDI > 15 events per hour (evidence of moderate-to-severe OSA)

Acceptable indicesApnea-hypopnea index (AHI), Respiratory Event Index (REI), Respiratory Disturbance Index (RDI)

Documentation requiredResults must be submitted in medical records demonstrating the index > 15 events/hour

inv-07: Reauthorization weight loss

Concurrent interventionsUsed in combination with a reduced-calorie diet and increased physical activity

Continued requirementPatient must continue to require treatment for obstructive sleep apnea

Initial Therapy Requirements

Initial therapy

Initial authorization criteria

Initial therapy: See Initial Authorization criteria: treatment for obstructive sleep apnea; patient ≥ 18 years old; BMI ≥ 30 kg/m2; moderate-to-severe OSA confirmed by sleep study (AHI, REI, or RDI > 15 events/hour); at least one prior unsuccessful dietary effort to lose weight; either continued symptoms despite PAP adherence (≥ 4 hours/night for ≥ 70% of nights) or not a candidate for PAP therapy; used with reduced calorie diet and increased physical activity; no diagnosis of diabetes or HgA1c > 6.5%; provider counseling on positional therapy and avoidance of alcohol/sedatives; no planned surgery for sleep apnea or obesity; no predominant central or mixed sleep apnea (>50% central/mixed events); prescribed by or in consultation with a sleep specialist

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.

Continuation branching: If patient has been on Zepbound for <52 weeks of consecutive therapy: authorize for 6 months. If patient has been on Zepbound for ≥52 weeks of consecutive therapy: medical records must confirm a 50% decrease from baseline in AHI, RDI, or REI after initiation and the patient must have achieved ≥ 10% weight loss from baseline to be eligible for a 12-month authorization.

Provider Responsibilities and Documentation

Prior Authorization

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

Note

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

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

inv-13: PAP adherence definition

AlternativePatient may be considered not a candidate for PAP (e.g., upper airway anatomic abnormalities) if adherence not achievable

DocumentationPrescriber must document adherence or ineligibility in medical records

inv-14: Moderate-to-severe OSA

Definition of moderate-to-severe OSASleep study showing AHI, REI, or RDI > 15 events per hour

Accepted measuresApnea-hypopnea index (AHI), Respiratory Event Index (REI), Respiratory Disturbance Index (RDI)

Step Therapy and Supply Constraints

Item	Limit / Notes
Supply limits
Supply limits may be in place.

Site of Care Considerations

Note

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.