Description

ZEPBOUND® is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist indicated in combination with a reduced-calorie diet and increased

physical activity:

• to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.
• to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.

Policy

Initial requests for Zepbound (tirzepatide) may be approved if the following criteria are met:

1. Submission of medical records documenting diagnosis of moderate to severe obstructive sleep apnea (OSA) confirmed by an apnea-hypopnea index (AHI) of greater than or equal to 15 events per hour measured by sleep study; AND
2. Submission of medical records documenting weight, height and BMI greater than or equal to 30 kg/m2; AND
3. Individual is 18 years of age or older; AND
4. Individual will be using this medication in combination with a reduced-calorie diet and increased physical activity; AND
5. Individual does not have a personal or family history of Medullary Thyroid Carcinoma (MTC); AND
6. Individual has not been diagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2); AND
7. Medication is not being used in combination with any of the following:
   1. Tirzepatide-containing products (e.g., Mounjaro)
   2. GLP-1 receptor agonists (e.g., Wegovy, Saxenda, Trulicity, Victoza, Ozempic, Rybelsus)

Initial approval duration: 6 months

Continuation requests for Zepbound (tirzepatide) may be approved if the following criteria are met:

1. Individual has a positive clinical response to therapy (e.g., symptom improvement such as less daytime sleepiness); AND
2. Individual is currently on a maintenance dose of 10 mg, 12.5 mg, or 15 mg once weekly; AND
3. Individual will be using this medication in combination with a reduced-calorie diet and increased physical activity; AND
4. Medication is not being used in combination with any of the following:
   1. Tirzepatide-containing products (e.g., Mounjaro)
   2. GLP-1 receptor agonists (e.g., Wegovy, Saxenda, Trulicity, Victoza, Ozempic, Rybelsus)

Continuation approval duration: 12 months

Please note, use of Zepbound for reduction of body weight without an indication of OSA is not a covered benefit.

References

1. DailyMed. Package insert. U.S. National Library of Medicine, National Institutes of Health website. http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed: January 8, 2025.
2. AASM. Obstructive sleep apnea. 2008, aasm.org/resources/factsheets/sleepapnea.pdf.
3. IPD Analytics. Zepbound for Obstructive Sleep Apnea.  January 2025. secure.ipdanalytics.com/User/Handler/ViewReport.ashx?type=RP&file=s3%3a%2f%2fipdanalytics%2fReports%2fIPD+Analytics_RxInsights_Zepbound+for+Obstructive+Sleep+Apnea_01+2025.pdf.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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