Zepbound (tirzepatide) — Point32Health

Initial criteria

• Patient age ≥ 18 years
• BMI ≥ 30 OR BMI 27–29 with one or more comorbid conditions (diabetes mellitus, hypertension, sleep apnea, hyperlipidemia, symptomatic osteoarthritis of the lower extremities, GERD, coronary heart disease with history of heart surgery, myocardial infarction, stroke, or angina)
• Used as adjunct to lifestyle modification (dietary or caloric restriction, exercise, behavioral support, or community-based program)
• If applicable for Value formulary, Premium formulary, and self-funded plans requiring plan-specified behavior modification program, confirmation of successful completion of 6 months of plan-specified behavior modification program

Reauthorization criteria

• Documented weight loss or maintenance of weight loss ≥ 5% of baseline body weight during first 6 months of treatment OR patient is new to the plan and stable on the medication (baseline and follow-up weights required)
• Documentation by prescribing physician of adherence to lifestyle modification (dietary or caloric restriction, exercise, behavioral support, or community-based program)

Approval duration

initial 6 months; reauth 1 year