Zepbound (tirzepatide) — CareFirst (Caremark)

Initial criteria

• The requested drug will be used with a reduced-calorie diet AND increased physical activity
• The patient is an adult
• The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) ≥ 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device
• The patient has a current body mass index (BMI) ≥ 30 kg/m2

Reauthorization criteria

• The requested drug will be used with a reduced-calorie diet AND increased physical activity
• The patient is an adult
• The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) ≥ 15 events per hour on PSG or HSAT with a technically adequate device
• The patient has achieved or maintained a positive response to treatment from baseline, evidenced by a decrease in OSA symptoms
• The patient is being treated with a maintenance dosage, 10 mg or 15 mg once weekly

Approval duration

Initial: 6 months; Continuation: 12 months