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
All of:
- Adult patient (18+)
- Established diagnosis of moderate to severe OSA with AHI >= 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device
- Current BMI >= 30 kg/m2
- Used with a reduced-calorie diet and increased physical activity
Documentation to bring
- Documentation of established diagnosis of moderate to severe OSA with AHI >= 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device
- Current BMI documentation (>= 30 kg/m2)
Quantity limits
- 2.5mg/0.5mL, 5mg/0.5mL, 7.5mg/0.5mL, 10mg/0.5mL, 12.5mg/0.5mL, 15mg/0.5mL — 2 mL (4 pre-filled single-dose pens) / 21 days; 6 mL (12 pre-filled single-dose pens) / 63 days (84-day)
- 2.5mg/0.6mL, 5mg/0.6mL, 7.5mg/0.6mL, 10mg/0.6mL, 12.5mg/0.6mL, 15mg/0.6mL — 2.4 mL (1 single-patient-use KwikPen) / 21 days; 7.2 mL (3 single-patient-use KwikPens) / 63 days (84-day)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for Patient must demonstrate a positive response to treatment from baseline evidenced by a decrease in OSA symptoms, and must be treated with a maintenance dosage based on individual treatment response and tolerability. OSA diagnosis (AHI >= 15) must be re-documented at continuation.
Not covered when
- Coadministration with other tirzepatide-containing products is not recommended
- Coadministration with any GLP-1 receptor agonist is not recommended
- Vials are excluded (covered under LillyDirect manufacturer program)
- OTC products are not included
Policy note: OSA must be moderate to severe (AHI >= 15 events/hour). No PAP/CPAP trial requirement is stated. Continuation requires documented decrease in OSA symptoms and treatment at a maintenance dose. The 28-day fill period uses 21-day supply and the 84-day fill period uses 63-day supply to allow time for refill processing.
verified June 2, 2026 · source: 6192-C_Zepbound.pdf