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Zepbound — Highmark

obstructive sleep apnea/hypopnea syndrome (OSAHS)

Preferred products

  • Ozempic
  • Mounjaro

Initial criteria

  • age ≥ 18 years
  • prescribed by or in consultation with a sleep specialist
  • diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • baseline polysomnography or recording time without positive airway pressure (PAP) or oral appliance demonstrating apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) ≥ 15 events per hour
  • baseline AHI or RDI with use of PAP or oral appliance documented by a device report or sleep study
  • baseline height, weight, and BMI provided
  • baseline BMI ≥ 30 kg/m2
  • EITHER member is currently receiving and compliant with PAP (device used ≥ 70% of nights for ≥ 4 hours/night for ≥ 2 months) OR (member experienced therapeutic failure, intolerance, or contraindication to PAP AND is using a custom titratable oral appliance prescribed by or in consultation with a sleep specialist AND has been adherent to oral appliance)
  • member maintained healthy dietary changes for at least 6 months prior to initiation and will continue them during therapy
  • member maintained increased physical activity for at least 6 months prior to initiation and will continue during therapy
  • member practiced sleep hygiene modifications (e.g., nonsupine sleep, avoid alcohol/sedatives before bed) for at least 6 months prior to initiation and will continue during therapy
  • member will not use Zepbound in combination with GLP-1 RAs or GLP-1 RA combinations
  • if Type 2 diabetes (ICD-10: E11.9), experienced therapeutic failure to a preferred GLP-1 RA approved to treat diabetes (e.g., Ozempic, Mounjaro)

Reauthorization criteria

  • age ≥ 18 years
  • prescribed by or in consultation with a sleep specialist
  • diagnosis of moderate to severe OSAHS (ICD-10: G47.33) prior to initiation
  • baseline AHI or RDI ≥ 15 documented by a sleep study without PAP or oral appliance
  • baseline AHI or RDI with PAP/oral appliance documented by sleep study or device report
  • ≥ 25% decrease from baseline (with PAP/oral appliance use prior to initiation) in AHI or RDI documented by device report or sleep study
  • member requires additional therapy with Zepbound to maintain decrease in AHI or RDI
  • baseline BMI ≥ 30 kg/m2
  • using therapy in combination with healthy dietary changes AND increased physical activity
  • practicing sleep hygiene modifications (e.g., nonsupine sleep, avoidance of alcohol/sedatives) with therapy
  • requested dose is 10 mg, 12.5 mg, or 15 mg once weekly OR prescriber attests titrating to 10 mg once weekly
  • member will not use Zepbound in combination with GLP-1 RAs or combinations
  • if Type 2 diabetes (ICD-10: E11.9), experienced therapeutic failure to a preferred GLP-1 RA approved to treat diabetes (e.g., Ozempic, Mounjaro)

Approval duration

Initiation: 7 months; Maintenance: 12 months