Zepbound (tirzepatide) — Point32Health

Moderate-to-Severe Obstructive Sleep Apnea in Obesity

Initial criteria

Patient age ≥ 18 years
Documented diagnosis of moderate-to-severe obstructive sleep apnea defined as apnea-hypopnea index (AHI) ≥ 15 events/hour on sleep study using American Academy of Sleep Medicine 1B hypopnea scoring method (Medicare criteria) with ≥ 4% oxygen desaturation, completed within last 2 years
Patient has body mass index (BMI) ≥ 30
Prescribed by a sleep specialist
Patient has history of unsuccessful dietary effort to lose body weight
Used as adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)
Documentation that patient has been evaluated and counseled on CPAP therapy and: (a) not able to tolerate CPAP despite reasonable adjustment attempts OR (b) not a candidate for CPAP therapy (e.g., upper airway anatomic abnormalities)
Patient does not have: (a) diagnosis of type 2 diabetes OR (b) NYHA class IV heart failure

Patient demonstrates positive clinical response (e.g., less daytime sleepiness, decreased 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 (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)
Submission of chart note or record confirming: (a) if therapy ≤ 6 months, weight loss ≥ 5% of baseline OR (b) if > 6 months, continues to experience or maintain weight loss
Patient does not have: (a) diagnosis of type 2 diabetes OR (b) NYHA class IV heart failure

initial 6 months; reauth 12 months