CurrentWashington State Health Care AuthorityPolicy 61.25.25.AA-1

Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)

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Washington Apple Health coverage and prior authorization requirements for Zepbound (tirzepatide) in adults with obesity and moderate to severe obstructive sleep apnea, including initial authorization, reauthorization, preferred-drug sequencing, documentation, and dosage requirements.

Policy Summary

PayerWashington State Health Care Authority

PolicyAnorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)

Policy CodePolicy 61.25.25.AA-1

Change TypeNew policy

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionDocument inadequate response or intolerance to at least two preferred agents before requesting approval of a non-preferred agent.

SourceLink

POLICY UPDATE CHANGES

A new policy was created establishing clinical coverage criteria for tirzepatide (Zepbound) for moderate to severe obstructive sleep apnea in adults with obesity.

AHI/RDI ≥15OSA threshold

BMI >30BMI threshold

6 monthsInitial authorization

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CurrentWashington State Health Care AuthorityPolicy 61.25.25.AA-1

Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 61.25.25.AA-1 alerts

Get alerted when Policy 61.25.25.AA-1 changes without checking for updates manually.

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Policy Summary

PayerWashington State Health Care Authority

PolicyAnorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)

Policy CodePolicy 61.25.25.AA-1

Change TypeNew policy

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionDocument inadequate response or intolerance to at least two preferred agents before requesting approval of a non-preferred agent.

SourceLink

POLICY UPDATE CHANGES

A new policy was created establishing clinical coverage criteria for tirzepatide (Zepbound) for moderate to severe obstructive sleep apnea in adults with obesity.

AHI/RDI ≥15OSA threshold

BMI >30BMI threshold

6 monthsInitial authorization

12 monthsReauthorization

15 mg weeklyMaximum dose

2Preferred agents required

Clinical Coverage Criteria

Initial therapy for moderate to severe obstructive sleep apnea in adults with obesity

Covered when all of the following documented criteria are met.

Initial therapy criteria

Age: Patient is at least 18 years of age.>= 18 years
Diabetes status: Patient does not have diabetes or HbA1c greater than 6.5%.HbA1c <= 6.5% and no diabetes
Patients with type 2 diabetes or HbA1c greater than 6.5% should request a GLP-1 agent indicated for type 2 diabetes under policy 27.17.00.
Obstructive sleep apnea diagnosis: Provider attests that the patient has moderate to severe obstructive sleep apnea, defined as an AHI or RDI of at least 15 obstructive respiratory events per hour without use of a positive airway pressure device (PAP).AHI or RDI >= 15 events per hour without PAP
Events include apneas, hypopneas, or RERAs.
PAP status
- Consulted and declined PAP: Patient was consulted about use of PAP and declined use of PAP.
- Unable to tolerate PAP: Patient is unable to tolerate PAP therapy.
- Using PAP: Patient is actively using PAP and will continue to use PAP.
Lifestyle intervention: Patient is engaged in lifestyle interventions including diet, exercise, and behavioral modification.
Concurrent GLP-1 therapy: Tirzepatide will not be used in combination with another GLP-1 agonist.No combination with another GLP-1 agonist
Obesity: Patient has a body mass index greater than 30 kg/m².> 30 kg/m²

Reauthorization

Reauthorized when all of the following documented criteria are met.

Reauthorization criteria

Prior authorization or established therapy: Member has received previous authorization approval or has been established on therapy from another health plan.
Samples, patient assistance programs, and coupons do not establish therapy for this criterion.
Continued clinical eligibility: Patient continues to meet criteria 1-6 above.
Positive clinical response: Documentation demonstrates a positive clinical response, such as weight loss, fewer AHIs per hour of sleep, or improved systolic blood pressure.
Examples in the policy are not exhaustive.

Tirzepatide must not be used in combination with another GLP-1 agonist.

Apple Health does not cover Zepbound for weight loss.

Use of Zepbound for weight loss is not covered by Apple Health.

Coding and Clinical Parameters

Regulatory and Statutory Referencesmixed

WAC 182-530-2100(1)b)(i)	Washington Administrative Code reference
SEC. 1927 [42 U.S.C. 1396r-8](d)(2)(A)	Federal Medicaid statutory reference

AgePatient is ≥ 18 years of age.

Obstructive Sleep Apnea SeverityProvider attestation of moderate to severe obstructive sleep apnea defined as AHI or RDI ≥ 15 obstructive respiratory events per hour (apneas, hypopneas, or RERAs), without use of a positive airway pressure device (PAP). Patient must have been consulted about PAP and either declined PAP, been unable to tolerate PAP therapy, or be actively using PAP and agree to continue using PAP.

Body Mass IndexBMI > 30 kg/m².

HbA1c Exclusion ThresholdPatient must not have diabetes or HbA1c > 6.5%. For patients with type 2 diabetes or HbA1c > 6.5%, request a GLP-1 agent indicated for type 2 diabetes under policy 27.17.00.

Prior Authorization and Provider Guidance

Prior Authorization

Preferred-Drug Trial Requirement

New-to-market drugs added to the Apple Health Preferred Drug List (AHPDL) are treated as non-preferred and require prior authorization. Before approval, the member must demonstrate an inadequate response or documented intolerance due to a severe adverse reaction or contraindication to preferred agents.

If there are at least two preferred agents in the class, document inadequate response or qualifying intolerance to at least two.
If there is only one preferred agent, document inadequate response or qualifying intolerance to that one agent.
Check the current AHPDL for preferred-agent status.

Note

Case-by-Case Medical Necessity Review

Zepbound may be considered medically necessary when the clinical-policy criteria are met. If one or more criteria are not met, the clinical reviewer may still determine that a medically necessary need exists and approve the request on a case-by-case basis.

For a member previously established on therapy who is new to Apple Health, the clinical reviewer may use the reauthorization criteria.

Background

Tirzepatide (Zepbound) is a GLP-1 receptor agonist indicated for the treatment of moderate to severe obstructive sleep apnea in adults with obesity. Treatment is used with lifestyle measures, including a reduced-calorie diet, increased physical activity, and behavioral modification. Positive airway pressure remains a traditional treatment option, and the policy allows coverage when the patient declines or cannot tolerate PAP, or is actively using and will continue PAP.

Definitions

Moderate to severe obstructive sleep apnea

Policy-specific thresholdAHI or RDI of at least 15 obstructive respiratory events per hour

Included respiratory eventsApneas, hypopneas, or respiratory effort-related arousals (RERAs)

Measurement conditionThe threshold is measured without use of a positive airway pressure device

Positive airway pressure (PAP)

DefinitionPositive airway pressure (PAP) is therapy that provides airway pressure during sleep

Included device typeContinuous positive airway pressure (CPAP)

Included device type

Policy Summary

PayerWashington State Health Care Authority

PolicyAnorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)

Policy CodePolicy 61.25.25.AA-1

Change TypeNew policy

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionDocument inadequate response or intolerance to at least two preferred agents before requesting approval of a non-preferred agent.

SourceLink

On This Page

Step Therapy

Preferred-Agent Step Therapy

Requests for a non-preferred agent must include documentation showing the required preferred-agent sequencing before the non-preferred agent can be approved.

Document an inadequate response or intolerance due to severe adverse reaction or contraindication to at least two preferred agents, or to the single preferred agent when only one is available.
Use the current Apple Health Preferred Drug List to identify preferred agents.

Documentation Required

Initial Clinical Documentation

For an initial authorization, submit documentation demonstrating that the patient meets all clinical criteria for treatment of moderate to severe obstructive sleep apnea in an adult with obesity.

Patient is 18 years or older.
Patient does not have diabetes and HbA1C is not greater than 6.5%; if the patient has type 2 diabetes or HbA1C greater than 6.5%, request a GLP-1 indicated for type 2 diabetes under Policy 27.17.00.
Provider attestation confirms moderate to severe obstructive sleep apnea, defined as AHI or RDI of at least 15 obstructive respiratory events per hour without PAP.
Document that the patient was consulted about PAP and either declined it, could not tolerate it, or is actively using it and will continue to use it.
Patient is engaged in lifestyle interventions, including diet, exercise, and behavioral modification.
Zepbound will not be used with another GLP-1 agonist.
BMI is greater than 30 kg/m².

Documentation Required

Reauthorization Documentation

For continued authorization, submit documentation showing ongoing eligibility and a positive clinical response to Zepbound.

Prior authorization approval is documented, or the patient was established on therapy through another health plan; establishment through samples, patient assistance programs, or coupons does not qualify.
The patient continues to meet clinical criteria 1–6 from the initial criteria.
Document a positive clinical response, such as weight loss, fewer AHIs per hour of sleep, or improved systolic blood pressure.

Denial Risk

Failure to Meet Initial Clinical Criteria

An initial request may be denied when the required clinical criteria are not documented or are not met. If all initial criteria are met, authorization is for 6 months.

Denial risk includes failure to document age, diabetes or HbA1C status, qualifying obstructive sleep apnea, PAP consultation or use status, lifestyle intervention, absence of concurrent GLP-1 therapy, or BMI greater than 30 kg/m².

Denial Risk

Failure to Meet Reauthorization Criteria

A continuation request may be denied when the member does not have qualifying prior authorization or established therapy, no longer meets the applicable clinical criteria, or lacks documentation of a positive clinical response. If all reauthorization criteria are met, authorization is for 12 months.

Therapy established through samples, patient assistance programs, or coupons does not satisfy the prior-authorization or established-therapy requirement.
A positive response must be documented, such as weight loss, fewer AHIs per hour of sleep, or improved systolic blood pressure.

Denial Risk

Preferred-Drug Sequencing Not Met

Failure to satisfy the preferred-drug sequence creates a step-therapy denial risk for a non-preferred agent, including a new-to-market drug classified as non-preferred on the AHPDL.

Document inadequate response or qualifying intolerance to the required preferred agents before requesting the non-preferred agent.
When only one preferred agent exists, documentation for that one agent is required.

Denial Risk

Weight-Loss-Only Use Excluded

Apple Health does not cover Zepbound when it is requested solely for weight loss. Requests must be supported by the covered clinical indication and documentation requirements for treatment of moderate to severe obstructive sleep apnea in an adult with obesity.

Weight-loss-only use is excluded from coverage.
Do not submit Zepbound solely for obesity or weight loss without the qualifying obstructive sleep apnea indication.

Bilevel positive airway pressure (BPAP)