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Centene · Osa

Centene coverage for Zepbound (Osa)

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • 6 months of a documented diet and exercise program
  • Prior trial of 3 other GLP-1 medications (Ozempic, Rybelsus, Trulicity, and liraglutide (generic Victoza)) for at least 90 days
  • Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy

Qualification pathways

You can qualify through any one of these.

Initial Approval – OSA (without concurrent T2DM)

All of:

  • Diagnosis of moderate to severe OSA confirmed by polysomnography or home sleep apnea test within past 12 months with AHI >= 15 respiratory events per hour
  • Age >= 18 years
  • BMI >= 30 kg/m2
  • Member does not have central or mixed sleep apnea
  • Active enrollment in physician-directed weight loss program for at least 6 months involving reduced calorie diet, increased physical activity, and behavioral modification, with plan to continue enrollment while on Zepbound
  • Zepbound not prescribed concurrently with other tirzepatide-containing products or any other GLP-1 receptor agonist
  • Documentation of member's baseline body weight in kg
  • Dose does not exceed escalation schedule (2.5mg wk1-4, 5mg wk5-8, 7.5mg wk9-12, 10mg wk13-16, 12.5mg wk17-20, 15mg wk21-24) and quantity limit (1 pen/vial per week for single-dose or 1 vial/KwikPen every 4 weeks for multi-dose)

Plus any one of:

  • Member has continued symptoms of OSA despite adherence to PAP therapy (>=4 hours/night for >=70% of nights)
  • Member is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)

Initial Approval – OSA with concurrent T2DM (Illinois HIM: step therapy waived as of 1/1/2026)

All of:

  • Diagnosis of moderate to severe OSA confirmed by polysomnography or home sleep apnea test within past 12 months with AHI >= 15 respiratory events per hour
  • Age >= 18 years
  • BMI >= 30 kg/m2
  • Member does not have central or mixed sleep apnea
  • Concurrent diagnosis of type 2 diabetes mellitus
  • Member has received optimal diabetic standard of care therapy as evidenced by a trial of >= 3 consecutive months each of ALL of: (1) Ozempic or Rybelsus, (2) Trulicity, and (3) liraglutide (generic Victoza), unless clinically significant adverse effects are experienced or all are contraindicated
  • If member is currently on a GLP-1 receptor agonist and requesting switch to Zepbound, medical justification supports necessity (intolerance due to common GI adverse effects is NOT acceptable justification)
  • Active enrollment in physician-directed weight loss program for at least 6 months involving reduced calorie diet, increased physical activity, and behavioral modification, with plan to continue enrollment while on Zepbound
  • Zepbound not prescribed concurrently with other tirzepatide-containing products or any other GLP-1 receptor agonist
  • Documentation of member's baseline body weight in kg
  • Dose does not exceed escalation schedule and quantity limit

Plus any one of:

  • Member has continued symptoms of OSA despite adherence to PAP therapy (>=4 hours/night for >=70% of nights)
  • Member is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)

Documentation to bring

  • Polysomnography or home sleep apnea test result within the past 12 months confirming AHI >= 15 respiratory events per hour
  • Documentation confirming absence of central or mixed sleep apnea
  • Documentation of member's baseline body weight in kg
  • Documentation of active enrollment in physician-directed weight loss program for at least 6 months (reduced calorie diet, increased physical activity, behavioral modification)
  • Documentation of continued enrollment in physician-directed weight loss program while on Zepbound
  • Documentation of PAP therapy adherence failure (>=4 hours/night for >=70% of nights with continued OSA symptoms) OR documentation that member is not a candidate for PAP therapy
  • For members with concurrent T2DM: Documentation of >= 3 consecutive months trial of each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) unless clinically significant adverse effects or contraindication documented (note: Illinois HIM waived as of 1/1/2026)
  • For members currently on a GLP-1 switching to Zepbound: Medical justification for the switch (GI intolerance to GLP-1 class is not acceptable)

Quantity limits

  • 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — Single-dose formulation: 4 pens or vials (1 per week); Multi-dose formulation: 1 vial or KwikPen every 4 weeks; Single-dose formulation: 12 pens or vials; Multi-dose formulation: 3 vials or KwikPens (84-day)

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, First renewal: member must have lost >=5% of baseline body weight AND show at least one of: AHI reduction from baseline, improvement in SASHB score, or improvement in sleep-related patient-reported outcomes (ESS, Calgary SAQLI, FOSQ, or PROMIS). Second and subsequent renewals: member must have lost weight and/or maintained weight loss AND show stabilization or improvement in AHI, SASHB, or sleep-related patient-reported outcomes. Maintenance dose must be >=10 mg once weekly after initial dose escalation. Continued enrollment in physician-directed weight loss program required. Step therapy (prior GLP-1 trial for T2DM comorbidity) is NOT re-verified at continuation. First reauthorization: 6 months; subsequent reauthorizations: 12 months, and staying on a maintenance dose of at least 10 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Central or mixed sleep apnea
  • Concurrent use with other tirzepatide-containing products
  • Concurrent use with any other GLP-1 receptor agonist
  • Personal or family history of medullary thyroid carcinoma (MTC) — contraindication
  • Multiple endocrine neoplasia syndrome type 2 (MEN 2) — contraindication
  • Known serious hypersensitivity to tirzepatide or any excipients in Zepbound — contraindication

Exceptions

  • Illinois_HIM: Step therapy requirements (prior GLP-1 trials for T2DM comorbidity and PAP therapy trial) do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: Policy applies to HIM/ICHRA and Medicaid lines of business. OSA must be moderate to severe (AHI >= 15). The prior GLP-1 step therapy requirement (Ozempic/Rybelsus, Trulicity, liraglutide) applies ONLY to members with concurrent T2DM. PAP therapy must have been attempted and failed (with adherence defined as >=4 hours/night >=70% of nights) or member must not be a candidate for PAP. Continuation requires maintenance dose >=10 mg weekly after dose escalation. First reauthorization approval: 6 months; subsequent reauthorizations: 12 months. Multi-dose vials and KwikPens are available in 10, 20, 30, 40, 50, 60 mg/2.4 mL concentrations corresponding to four doses per vial/pen.

Policy effective December 20, 2024 · verified June 2, 2026 · source: CP.PMN.298.pdf

All Zepbound policies under Centene · Check your card