Zepbound (tirzepatide) — Point32Health

Initial criteria

• Patient age ≥ 18 years
• Documented diagnosis of moderate-to-severe obstructive sleep apnea defined as apnea-hypopnea index (AHI) ≥ 15 events per hour on sleep study
• BMI ≥ 30
• Used as adjunct to lifestyle modification (dietary or caloric restriction, exercise, behavioral support, or community-based program)
• Evaluated and counseled on continuous positive airway pressure (CPAP) therapy as preferred treatment OR not a candidate for CPAP therapy (e.g., upper airway anatomic abnormalities)

Reauthorization criteria

• Patient demonstrates positive clinical response to therapy (reduced daytime sleepiness or decrease in respiratory events per hour of sleep)
• Patient currently on maintenance dose of 10 mg or 15 mg once weekly
• Used as adjunct to lifestyle modification (dietary or caloric restriction, exercise, behavioral support, or community-based program)
• Weight loss ≥ 5% of baseline body weight after ≤ 6 months of therapy OR continuing weight loss or maintenance of weight loss after > 6 months of therapy

Approval duration

initial 6 months; reauth 1 year