Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial approval — obesity (BMI ≥ 30)
All of:
- Drug used with reduced calorie diet and increased physical activity for chronic weight management in an adult
- Patient has participated in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity with continuing follow-up) for at least 6 months prior to drug therapy
- Baseline BMI ≥ 30 kg/m² (documentation required)
Initial approval — overweight with comorbidity (BMI ≥ 27)
All of:
- Drug used with reduced calorie diet and increased physical activity for chronic weight management in an adult
- Patient has participated in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity with continuing follow-up) for at least 6 months prior to drug therapy
- Baseline BMI ≥ 27 kg/m² (documentation required)
- At least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia) (documentation required)
Continuation of therapy
All of:
- Patient has completed at least 3 months of therapy with Zepbound at a stable maintenance dose
Plus any one of:
- Patient has lost at least 5% of baseline body weight
- Patient has continued to maintain their initial 5% weight loss
Documentation to bring
- Baseline BMI documentation (≥ 30 kg/m² for obesity pathway, or ≥ 27 kg/m² for overweight pathway)
- Documentation of qualifying weight-related comorbid condition (e.g., hypertension, T2DM, dyslipidemia) if BMI ≥ 27 but < 30
- Documentation of participation in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity with continuing follow-up) for at least 6 months prior to drug therapy (initial pathway)
- Documentation of at least 3 months of therapy at a stable maintenance dose (continuation pathway)
- Documentation of at least 5% baseline body weight loss or maintenance of initial 5% weight loss (continuation pathway)
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 (1 package of 4 pens) / 21-day supply within 28-day fill period; 6 mL (3 packages of 4 pens each) / 63-day supply within 84-day fill period (84-day)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- Renewal: At continuation, patient must have lost at least 5% of baseline body weight OR continued to maintain their initial 5% weight loss. Patient must also have completed at least 3 months of therapy at a stable maintenance dose. The 6-month lifestyle program requirement is NOT re-checked at continuation.
- Renewal: At least 12 weeks on therapy before the first renewal.
Not covered when
- Coadministration with other tirzepatide-containing products is not recommended
- Coadministration with any GLP-1 receptor agonist is not recommended
- Coadministration with other weight management products (prescription, OTC, or herbal) has not been established
- Not studied in patients with history of pancreatitis
Policy note: Policy number 6192-C, updated UDR 11-2023. Two distinct pathways exist: (1) new start requiring prior 6-month lifestyle program plus BMI criteria, and (2) continuation requiring 3 months at stable dose plus 5% weight loss or maintenance. The quantity limit note specifies 21-day and 63-day supply durations to allow time for refill processing within 28-day and 84-day fill windows respectively. No OSA-specific indication criteria are documented in this policy despite OSA being listed as an FDA-approved comorbidity for the overweight (BMI ≥ 27) threshold.
verified June 5, 2026 · source: 14017 156760115 · View policy document (PDF)