Zepbound (tirzepatide) — Prior authorization for obstructive sleep apnea
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Prior authorization policy for coverage of Zepbound (tirzepatide) specifically to treat moderate-to-severe obstructive sleep apnea in adults with obesity; governs medical necessity requirements and authorization durations for UnitedHealthcare plans where applicable.
Program created to allow coverage of Zepbound for obesity with obstructive sleep apnea despite typical weight-loss medication exclusions.
Requirement for symptoms of obstructive sleep apnea was removed.
Requirement to not have significant craniofacial abnormalities was removed.
Added description and handling of mixed and central apneas.
Coverage Criteria for Zepbound (tirzepatide)
Initial Therapy
Covered when ALL of the following are met
Authorization: 6 months
Continuation / Reauthorization
Reauthorization approved when ALL of the following are met
Patients with a diagnosis of predominant central or mixed sleep apnea are excluded. Predominant central or mixed sleep apnea is defined as when the percent of mixed or central apneas/hypopneas is >50% of all respiratory events. The prescriber must attest the patient does not have this diagnosis as part of the initial authorization documentation; presence of predominant central or mixed events will make the request ineligible for coverage.
Although medications for weight loss are typically excluded from coverage, this program limits Zepbound coverage to the obstructive sleep apnea (OSA) indication only. The policy allows coverage of Zepbound when it is being used to treat moderate-to-severe OSA in adults with obesity and all clinical criteria for OSA treatment are met; other indications for chronic weight management remain subject to standard benefit exclusions.
Clinical Thresholds and Coding-Related Criteria
Provider Requirements and Documentation
Prior Authorization Required
Prior authorization required. Initial approval issued for 6 months when all initial criteria are met.
- Initial authorization required for Zepbound when ALL initial criteria are met
- Authorization term: 6 months
Denial Risk — Age and Exclusions
Denial risk if patient is under 18 years of age or other exclusion criteria are present.
- Patient must be ≥ 18 years old — requests for patients < 18 years have high risk of denial
- Denial risk if diagnosis is predominant central or mixed sleep apnea (>50% central/mixed events)
- Denial risk if planned surgery for sleep apnea or obesity is documented
PAP Therapy Trial Requirement
Requires previous trial and adherence to positive airway pressure (PAP) therapy unless the patient is not a candidate.
- Documentation that patient has continued OSA symptoms despite adherence to PAP therapy defined as ≥ 4 hours/night on ≥ 70% of nights
- If patient is not a candidate for PAP (e.g., upper airway anatomic abnormalities), document reason
Documentation Submission Required
Submit medical records documenting required baseline clinical information to support the request.
- BMI ≥ 30 kg/m2 documented
- Sleep study results showing moderate-to-severe OSA (AHI, REI, or RDI > 15 events/hour)
- Documentation of at least one prior unsuccessful dietary weight-loss effort
- Evidence of counseling on positional therapy and avoidance of alcohol/sedatives before bedtime
- Confirmation patient does not have diabetes with HbA1c > 6.5% or planned related surgery
- Prescriber specialty: prescribed by or in consultation with a sleep specialist
Initial Therapy — Medical Necessity Logic
Initial therapy — Initial approval criteria and duration
Initial approval criteria and duration
Authorization duration: 6 months
Reauthorization / Continuation Criteria
Reauthorization — Reauthorization requirements and durations
Reauthorization requirements and durations
Also requires ≥10% weight loss from baseline and continued need for OSA treatment
Step Therapy Requirements
| Step | Requirement | Notes |
|---|---|---|
| 1 | Prior attempt at positive airway pressure (PAP) therapy with documented adherence | Adherence defined as ≥4 hours/night for ≥70% of nights; coverage allowed if patient continues to have OSA symptoms despite adherence |
| 1 | OR documented not a candidate for PAP therapy | Examples include upper airway anatomic abnormalities or other contraindications to PAP; documentation must support why PAP is not appropriate |
Definitions and Key Terms
Background
Zepbound (tirzepatide) is a dual incretin receptor agonist acting as a GIP and GLP-1 receptor agonist. It is indicated to treat moderate-to-severe obstructive sleep apnea in adults with obesity and, separately, for chronic weight management in adults with obesity or overweight with at least one weight-related comorbidity. This policy permits coverage of Zepbound specifically for the OSA indication when the program’s medical necessity criteria are satisfied.
Quantity Limits and Supply
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