Highmark

Does Highmark cover Zepbound?

Quick answer · Weight Loss

Highmark covers it only when the plan's benefit includes it on Employer / Commercial Insurance and ACA Marketplace.

  • Employer / Commercial Insurance: Depends on your plan's benefit. Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.
  • ACA Marketplace: Depends on your plan's benefit. Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.

Last verified June 2, 2026. Policy effective April 24, 2026. Source: J-1388-027.pdf. How we verify this data →

Check your card for your exact plan →

Zepbound for Weight Loss

What Highmark requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Depends on your plan's benefit

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.

What you need to qualify

  • Age 18 and older
  • BMI of 40 or higher
  • Diagnosis documented with a code (E66.0, E66.3)
  • 6 months of a documented diet and exercise program
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Adult Initiation (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member has one of the following clinical manifestations of organ dysfunction directly caused by obesity: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member has at least two of the following clinical manifestations of organ dysfunction directly caused by obesity: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Adult Maintenance (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current height, weight, and BMI documented
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained >= 7.5% weight loss from baseline
  • Requested dose is 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly
  • >= 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member had one of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member had at least two of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 40 kg/m2)
  • For qualifying via metabolic pathway: lab results within 6 months showing prediabetes (A1C 5.7-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women)
  • For qualifying via organ dysfunction pathway: clinical documentation of qualifying comorbidity (coronary artery disease, MASH F2-F3, MI, stroke, PAD, peripheral vascular disease, or moderate-to-severe OSA) OR at least two qualifying comorbidities from the secondary list
  • Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: current height, weight, and BMI
  • For maintenance: documentation of >= 7.5% weight loss from baseline
  • For maintenance: documentation or attestation that requested dose is a maintenance dose (5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly) or titrating to 5 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 7.5% weight loss from the starting weight, For adult maintenance (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Qualifying comorbidity (prediabetes+labs, or organ dysfunction) at baseline is re-verified at continuation. Maintenance dose requirements: Zepbound 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly, and staying on a maintenance dose of at least 5 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • Zepbound single-dose vials are only available for self-pay patients with an on-label prescription; vials cannot be billed through insurance coverage
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Delaware Commercial fully-insured and Healthcare Reform members without the anti-obesity benefit may access Zepbound coverage only for OSA (Section VI), not for weight loss under Section IV.

Policy note: Zepbound is the plan-preferred agent for weight loss in the GLP-1/GIP class. The adult weight loss criteria require BMI >= 40 with a qualifying comorbidity — this is substantially higher than FDA label thresholds (>= 27 with comorbidity or >= 30 without). There is no adolescent pathway for Zepbound under weight loss (adolescent weight loss only covers Saxenda and Wegovy injection, per Section III). The 2.5 mg dose is for initiation only and is not a maintenance dose. If pancreatitis occurs, member should not switch to another GLP-1 agent. Members established on samples or out-of-pocket will only be granted continuation if policy criteria are met. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

ACA Marketplace

Depends on your plan's benefit

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.

What you need to qualify

  • Age 18 and older
  • BMI of 40 or higher
  • Diagnosis documented with a code (E66.0, E66.3)
  • 6 months of a documented diet and exercise program
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Adult Initiation (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member has one of the following clinical manifestations of organ dysfunction directly caused by obesity: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member has at least two of the following clinical manifestations of organ dysfunction directly caused by obesity: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Adult Maintenance (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current height, weight, and BMI documented
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained >= 7.5% weight loss from baseline
  • Requested dose is 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly
  • >= 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member had one of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member had at least two of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 40 kg/m2)
  • For qualifying via metabolic pathway: lab results within 6 months showing prediabetes (A1C 5.7-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women)
  • For qualifying via organ dysfunction pathway: clinical documentation of qualifying comorbidity (coronary artery disease, MASH F2-F3, MI, stroke, PAD, peripheral vascular disease, or moderate-to-severe OSA) OR at least two qualifying comorbidities from the secondary list
  • Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: current height, weight, and BMI
  • For maintenance: documentation of >= 7.5% weight loss from baseline
  • For maintenance: documentation or attestation that requested dose is a maintenance dose (5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly) or titrating to 5 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 7.5% weight loss from the starting weight, For adult maintenance (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Qualifying comorbidity (prediabetes+labs, or organ dysfunction) at baseline is re-verified at continuation. Maintenance dose requirements: Zepbound 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly, and staying on a maintenance dose of at least 5 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • Zepbound single-dose vials are only available for self-pay patients with an on-label prescription; vials cannot be billed through insurance coverage
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Delaware Commercial fully-insured and Healthcare Reform members without the anti-obesity benefit may access Zepbound coverage only for OSA (Section VI), not for weight loss under Section IV.

Policy note: Zepbound is the plan-preferred agent for weight loss in the GLP-1/GIP class. The adult weight loss criteria require BMI >= 40 with a qualifying comorbidity — this is substantially higher than FDA label thresholds (>= 27 with comorbidity or >= 30 without). There is no adolescent pathway for Zepbound under weight loss (adolescent weight loss only covers Saxenda and Wegovy injection, per Section III). The 2.5 mg dose is for initiation only and is not a maintenance dose. If pancreatitis occurs, member should not switch to another GLP-1 agent. Members established on samples or out-of-pocket will only be granted continuation if policy criteria are met. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

Zepbound for Osa

What Highmark requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Depends on your plan's benefit

Section VI applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit only. For members WITH the anti-obesity benefit, Zepbound for OSA may be covered under that benefit (criteria not fully specified in this section for those members). The document frames Section VI as the pathway for DE members without obesity benefit.

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • Diagnosis documented with a code (G47.33)
  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • 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.

OSA Initiation (Section VI) - PAP-compliant pathway

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member is currently receiving and compliant with PAP, documented by device report showing device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA Initiation (Section VI) - PAP-intolerant pathway with oral appliance

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member has experienced therapeutic failure, intolerance, or contraindication to PAP
  • Member is using a custom, titratable oral appliance
  • Oral appliance prescribed by or in consultation with a sleep specialist
  • Prescriber documents that member has been adherent to the oral appliance
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA — T2DM step therapy (if applicable)

All of:

  • If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes (e.g., Ozempic, Mounjaro)

OSA Maintenance (Section VI)

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Member had a diagnosis of moderate to severe OSAHS (ICD-10: G47.33) prior to initiation of requested therapy
  • Baseline polysomnography demonstrating AHI or RDI >= 15 events per hour (sleep study)
  • Baseline AHI or RDI with use of PAP or oral appliance documented by sleep study or device report
  • Baseline BMI >= 30 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Table A documentation of continued dietary changes and physical activity
  • Chart note documentation that member is practicing sleep hygiene modifications in combination with therapy
  • Requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, OR prescriber attests titrating to 10 mg once weekly
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • >= 7 months of previous therapy

Plus any one of:

  • Decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation of Zepbound) as documented by PAP device report or sleep study
  • If baseline AHI/RDI with PAP or oral appliance use prior to Zepbound initiation was 0, then AHI/RDI remained at 0 as documented by PAP device report or sleep study

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 30 kg/m2)
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Documentation of baseline AHI or RDI WITH use of PAP or oral appliance (device report or sleep study)
  • Prescription by or consultation with a sleep specialist
  • For PAP-compliant pathway: PAP device report demonstrating device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • For PAP-intolerant pathway: documentation of PAP therapeutic failure, intolerance, or contraindication; documentation of current use of custom titratable oral appliance prescribed by sleep specialist; documentation of oral appliance adherence
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Chart notes documenting sleep hygiene modifications (sleep positioning to avoid supine, avoidance of alcohol and sedatives before bed) practiced for at least 6 months prior to initiation
  • If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA approved for diabetes (e.g., Ozempic, Mounjaro)
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: documentation of >= 25% decrease from baseline AHI/RDI (with prior PAP/OA use) OR documentation that AHI/RDI remained at 0 (if baseline was 0), via PAP device report or sleep study
  • For maintenance: documentation that member requires continued Zepbound to maintain the AHI/RDI reduction
  • For maintenance: documentation or attestation that requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, or titrating to 10 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for For OSA maintenance: member must demonstrate a decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation) as documented by PAP device report or sleep study; OR if baseline AHI/RDI with PAP/OA was 0, the AHI/RDI remains at 0. Member must require additional therapy with Zepbound to maintain the AHI/RDI decrease. Maintenance dose: 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 10 mg once weekly. T2DM step therapy requirement (failure of preferred diabetes GLP-1 RA) is re-verified at continuation. Ongoing PAP/OA use compliance and sleep specialist oversight continue to be required and staying on a maintenance dose of at least 10 mg.

Not covered when

  • AHI or RDI < 15 events per hour at baseline (Zepbound has not been studied at lower AHI)
  • BMI < 30 kg/m2 at baseline (Zepbound has not been studied below this threshold for OSA)
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • If T2DM (E11.9): must have failed preferred diabetes GLP-1 RA (e.g., Ozempic, Mounjaro) before Zepbound approved for OSA
  • Zepbound single-dose vials are only available for self-pay patients; vials cannot be billed through insurance
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Section VI (OSA indication) explicitly applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit. Members with the obesity benefit may also access Zepbound for OSA but the applicable criteria section for those members is less explicitly stated.

Policy note: Zepbound for OSA requires a sleep specialist (prescription by or consultation with). PAP compliance is required as a prerequisite OR documented failure/intolerance/contraindication to PAP with current compliant use of a custom titratable oral appliance. The AHI/RDI threshold of >= 15 corresponds to moderate-to-severe OSA. For continuation, a >= 25% reduction in AHI/RDI from the baseline-with-PAP/OA value must be demonstrated. The maintenance dose minimum for OSA is 10 mg once weekly (higher than the 5 mg minimum for weight loss). If T2DM, must first fail a preferred diabetes GLP-1 RA. Sleep hygiene modifications are required both prior to initiation and ongoing. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

ACA Marketplace

Depends on your plan's benefit

Section VI applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit only. For members WITH the anti-obesity benefit, Zepbound for OSA may be covered under that benefit (criteria not fully specified in this section for those members). The document frames Section VI as the pathway for DE members without obesity benefit.

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • Diagnosis documented with a code (G47.33)
  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • 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.

OSA Initiation (Section VI) - PAP-compliant pathway

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member is currently receiving and compliant with PAP, documented by device report showing device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA Initiation (Section VI) - PAP-intolerant pathway with oral appliance

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member has experienced therapeutic failure, intolerance, or contraindication to PAP
  • Member is using a custom, titratable oral appliance
  • Oral appliance prescribed by or in consultation with a sleep specialist
  • Prescriber documents that member has been adherent to the oral appliance
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA — T2DM step therapy (if applicable)

All of:

  • If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes (e.g., Ozempic, Mounjaro)

OSA Maintenance (Section VI)

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Member had a diagnosis of moderate to severe OSAHS (ICD-10: G47.33) prior to initiation of requested therapy
  • Baseline polysomnography demonstrating AHI or RDI >= 15 events per hour (sleep study)
  • Baseline AHI or RDI with use of PAP or oral appliance documented by sleep study or device report
  • Baseline BMI >= 30 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Table A documentation of continued dietary changes and physical activity
  • Chart note documentation that member is practicing sleep hygiene modifications in combination with therapy
  • Requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, OR prescriber attests titrating to 10 mg once weekly
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • >= 7 months of previous therapy

Plus any one of:

  • Decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation of Zepbound) as documented by PAP device report or sleep study
  • If baseline AHI/RDI with PAP or oral appliance use prior to Zepbound initiation was 0, then AHI/RDI remained at 0 as documented by PAP device report or sleep study

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 30 kg/m2)
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Documentation of baseline AHI or RDI WITH use of PAP or oral appliance (device report or sleep study)
  • Prescription by or consultation with a sleep specialist
  • For PAP-compliant pathway: PAP device report demonstrating device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • For PAP-intolerant pathway: documentation of PAP therapeutic failure, intolerance, or contraindication; documentation of current use of custom titratable oral appliance prescribed by sleep specialist; documentation of oral appliance adherence
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Chart notes documenting sleep hygiene modifications (sleep positioning to avoid supine, avoidance of alcohol and sedatives before bed) practiced for at least 6 months prior to initiation
  • If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA approved for diabetes (e.g., Ozempic, Mounjaro)
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: documentation of >= 25% decrease from baseline AHI/RDI (with prior PAP/OA use) OR documentation that AHI/RDI remained at 0 (if baseline was 0), via PAP device report or sleep study
  • For maintenance: documentation that member requires continued Zepbound to maintain the AHI/RDI reduction
  • For maintenance: documentation or attestation that requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, or titrating to 10 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for For OSA maintenance: member must demonstrate a decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation) as documented by PAP device report or sleep study; OR if baseline AHI/RDI with PAP/OA was 0, the AHI/RDI remains at 0. Member must require additional therapy with Zepbound to maintain the AHI/RDI decrease. Maintenance dose: 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 10 mg once weekly. T2DM step therapy requirement (failure of preferred diabetes GLP-1 RA) is re-verified at continuation. Ongoing PAP/OA use compliance and sleep specialist oversight continue to be required and staying on a maintenance dose of at least 10 mg.

Not covered when

  • AHI or RDI < 15 events per hour at baseline (Zepbound has not been studied at lower AHI)
  • BMI < 30 kg/m2 at baseline (Zepbound has not been studied below this threshold for OSA)
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • If T2DM (E11.9): must have failed preferred diabetes GLP-1 RA (e.g., Ozempic, Mounjaro) before Zepbound approved for OSA
  • Zepbound single-dose vials are only available for self-pay patients; vials cannot be billed through insurance
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Section VI (OSA indication) explicitly applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit. Members with the obesity benefit may also access Zepbound for OSA but the applicable criteria section for those members is less explicitly stated.

Policy note: Zepbound for OSA requires a sleep specialist (prescription by or consultation with). PAP compliance is required as a prerequisite OR documented failure/intolerance/contraindication to PAP with current compliant use of a custom titratable oral appliance. The AHI/RDI threshold of >= 15 corresponds to moderate-to-severe OSA. For continuation, a >= 25% reduction in AHI/RDI from the baseline-with-PAP/OA value must be demonstrated. The maintenance dose minimum for OSA is 10 mg once weekly (higher than the 5 mg minimum for weight loss). If T2DM, must first fail a preferred diabetes GLP-1 RA. Sleep hygiene modifications are required both prior to initiation and ongoing. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

Why Zepbound requests get denied by Highmark

Based on what this policy asks for. Fix these before the first submission.

  1. Your specific plan doesn't include the weight loss benefit. Coverage here is conditional on the benefit design (often an optional employer add-on), so confirm it before submitting.
  2. Wrong brand for the diagnosis. Zepbound and Mounjaro are the same molecule with different approved uses; a request for Zepbound under a diagnosis that matches Mounjaro is routinely denied.
  3. Diagnosis code missing or wrong on the request.
  4. BMI not documented in the chart notes (or documented without a baseline weight and date).
  5. No documented diet and exercise program.
  6. Prescriber isn't the specialist the plan requires.
  7. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

If weight loss isn't covered on your plan

Highmark has separate Zepbound policies that don't depend on the weight loss benefit:

  • Osa — covered on Employer / Commercial Insurance and ACA Marketplace.

Zepbound is also sold directly by Eli Lilly without insurance through LillyDirect.

Frequently asked questions

Does Highmark cover Zepbound?
Highmark covers it only when the plan's benefit includes it on Employer / Commercial Insurance and ACA Marketplace.
What BMI do you need for Zepbound under Highmark?
For weight loss on Employer / Commercial Insurance plans, Highmark requires a BMI of 40 or higher. Other plan types may differ — see each plan type below.
How long does a Zepbound approval last with Highmark?
Initial approvals last 7 months, and renewals are granted in 12-month periods.
What does Highmark require to renew Zepbound?
At least 7.5% weight loss from the starting weight, For adult maintenance (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Qualifying comorbidity (prediabetes+labs, or organ dysfunction) at baseline is re-verified at continuation. Maintenance dose requirements: Zepbound 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly, and staying on a maintenance dose of at least 5 mg.
What if my plan excludes weight loss medications?
Highmark has separate Zepbound policies for osa, which are covered on some plan types and don't depend on the weight-loss benefit. Zepbound is also available for cash through LillyDirect.
How current is this information?
This page reflects Highmark's written policy as of April 24, 2026, last verified against the source document on June 2, 2026.

Other medications under Highmark

Zepbound coverage under other plans

All insurance plans · All medications

This page summarizes Highmark's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.