Kaiser Permanente Northwest coverage for Zepbound (Osa)

Covered under the prescription drug benefit for weight loss ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss. Others pay member cash price. For OSA indication, weight loss benefit coverage is implicitly required as the same benefit structure applies.

What you need to qualify

• Age 18 and older
• BMI of 30 or higher
• Prior trial of another GLP-1 medication (semaglutide (Ozempic/Wegovy)) for at least 180 days
• Prior trial of phentermine, diethylpropion, topiramate, Qsymia, and Contrave for at least 3 months
• Diagnosed obstructive sleep apnea (AHI of 30 or higher)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of no personal or family history of MTC or MEN 2
• Documentation confirming absence of central or complex apnea
• Documentation confirming no diagnosis of diabetes
• Sleep study results within the last 3 years with AHI >= 30 (study weight within +/- 3 months of study date)
• Documentation that patient has not lost more than 5% body weight since the time of the sleep study
• Diagnosis of severe obstructive sleep apnea (AHI >= 30)
• Patient age >= 18 years
• Current weight and BMI documented within the last 30 days
• Documentation of current diet and exercise program participation
• BMI >= 30 kg/m2
• Documentation of failed adequate trial (>=3 months each) of at least two of: phentermine, diethylpropion, topiramate, Qsymia, Contrave; OR documentation of allergy/intolerance/contraindication to ALL listed therapies (not required for Medicare Part D or Washington Medicare patients)
• Documentation of failed minimum 6-month trial of semaglutide (Ozempic/Wegovy) with bariatric medicine chart review supporting need to switch; OR documentation of allergy/intolerance/contraindication to semaglutide (not required for Medicare Part D or Washington Medicare patients)

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Patient must have achieved and maintained 5% or greater weight loss after starting tirzepatide (Zepbound). Updated weight and BMI must be recently documented. Initial criteria (OSA diagnosis, sleep study, prior therapy trials, BMI threshold) are not re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Personal or family history of medullary thyroid carcinoma (MTC)
• Personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Central or complex apnea
• Diagnosis of diabetes (this OSA pathway explicitly requires absence of diabetes diagnosis)
• No weight loss prescription drug benefit (for OSA pathway, same benefit structure applies)

Exceptions

• note: The non-GLP-1 step therapy requirement (phentermine, diethylpropion, topiramate, Qsymia, Contrave) does NOT apply to Medicare Part D patients or Washington Medicare patients. The prior semaglutide step therapy requirement also does NOT apply to Medicare Part D patients or Washington Medicare patients.

Policy note: OSA indication requires diagnosis of SEVERE sleep apnea (AHI >= 30, not merely moderate). No PAP/CPAP trial requirement stated. Patient must not have a diabetes diagnosis to qualify under this pathway (diabetes patients use the T2DM pathway). Adequate trial is defined as a 3-month treatment duration. Intolerance excludes adverse drug reactions that are expected, mild in nature, resolve with continued treatment, and do not require medication discontinuation. The ** footnote exemptions (Medicare Part D and Washington Medicare patients) apply to both the non-GLP-1 and prior semaglutide step therapy requirements.

Policy effective June 4, 2026 · verified June 5, 2026 · source: kp-zepbound-nw-en.pdf