Zepbound (tirzepatide) — United Healthcare

Initial criteria

• Treatment is being requested for obstructive sleep apnea
• age ≥ 18 years
• Submission of medical records documenting ALL of the following:
• BMI ≥ 30 kg/m2
• Moderate-to-severe obstructive sleep apnea evidenced by BOTH of the following:
• - a sleep study
• - ONE of the following: apnea-hypopnea index (AHI) > 15 events/hour OR respiratory event index (REI) > 15 events/hour OR respiratory disturbance index (RDI) > 15 events/hour
• Patient has symptoms consistent with OSA such as excessive daytime sleepiness, loud snoring, choking, gasping, difficulty maintaining sleep, or impairment in daily functioning related to OSA
• At least one previous unsuccessful dietary effort to lose weight
• ONE of the following:
• - Patient has continued symptoms of OSA despite adherence to positive airway pressure (PAP) therapy (adherence defined as ≥ 4 hours/night for ≥ 70% of nights)
• - Patient is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)
• Used in combination with a reduced calorie diet and increased physical activity
• Patient does not have a diagnosis of diabetes or HbA1c > 6.5%
• Provider attests to BOTH of the following:
• - patient counseled on appropriate positional therapy
• - patient counseled on avoidance of alcohol and/or sedatives before bedtime
• Prescriber attests patient does NOT have ANY of the following:
• - planned surgery for sleep apnea or obesity
• - significant craniofacial abnormalities
• - diagnosis of central or mixed sleep apnea
• Prescribed by or in consultation with a sleep specialist

Reauthorization criteria

• ONE of the following:
• - BOTH of the following:
• - Patient has been on Zepbound < 52 weeks of consecutive therapy
• - Submission of medical records confirming a decrease from baseline in ONE of the following: AHI, RDI, or REI
• - BOTH of the following:
• - Patient has been on Zepbound ≥ 52 weeks of consecutive therapy
• - Submission of medical records confirming a 50% decrease from baseline in ONE of the following: AHI, RDI, or REI
• AND Patient has had a weight loss ≥ 10% of baseline body weight
• AND Used in combination with a reduced calorie diet and increased physical activity
• AND Patient does not have a diagnosis of diabetes or HbA1c > 6.5%
• AND Patient continues to require treatment for obstructive sleep apnea

Approval duration

Initial: 6 months; Reauthorization: 6 months if <52 weeks of therapy or 12 months if ≥52 weeks of therapy