Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- Diagnosed obstructive sleep apnea (AHI of 15 or higher)
Qualification pathways
You can qualify through any one of these.
Moderate to severe OSA with obesity - initial approval
All of:
- Request is for tirzepatide (Zepbound/Mounjaro)
- Established diagnosis of moderate to severe OSA with AHI >= 15 events/hour on PSG or HSAT with technically adequate device
- Current BMI >= 30 kg/m2
- Used with reduced-calorie diet AND increased physical activity
Documentation to bring
- Documentation of moderate to severe OSA diagnosis with AHI >= 15 events/hour on PSG or HSAT with technically adequate device
- Current BMI documentation (>= 30 kg/m2)
Quantity limits
- 2.5 mg/0.5 mL, 5 mg/0.5 mL, 7.5 mg/0.5 mL, 10 mg/0.5 mL, 12.5 mg/0.5 mL, 15 mg/0.5 mL — 2 mL (4 pre-filled single-dose pens) / 21 days; 6 mL (12 pre-filled single-dose pens) / 63 days (84-day)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for Positive response to treatment from baseline evidenced by a decrease in OSA symptoms. Patient must be treated with maintenance dosage based on individual treatment response and tolerability. AHI documentation is re-required at continuation.
Not covered when
- Zepbound vials and Zepbound Kwikpens are covered under the LillyDirect manufacturer program and not under this policy
- No PAP/CPAP trial required prior to approval
Policy note: Policy uses 'current BMI >= 30' (not baseline) for OSA indication. No PAP/CPAP prior therapy requirement stated. OSA must be moderate to severe (AHI >= 15 events/hour). Policy refers to tirzepatide as 'Zepbound/Mounjaro' jointly for OSA criteria, though Mounjaro is not FDA-approved for OSA — Mounjaro is FDA-approved only for T2DM. The OSA criteria section header says 'Tirzepatide (Zepbound/Mounjaro) ONLY' suggesting Mounjaro could be approved for this off-label use under this policy.
Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html