You can qualify through any one of these.
Initial approval — moderate to severe OSA with obesity
All of:
- Patient is ≥18 years of age
- Patient does not have diabetes and does not have HbA1C >6.5%
- Provider attestation that patient has moderate to severe OSA defined as AHI or RDI ≥15 obstructive respiratory events per hour (apneas, hypopneas, or RERAs), without the use of a PAP device
- Patient meets one of the PAP criteria (consulted and declined PAP, unable to tolerate PAP, or actively using PAP and will continue to use PAP)
- Patient is engaged in lifestyle interventions including diet, exercise, and behavioral modification
- Tirzepatide will not be used in combination with another GLP-1 agonist
- Patient has a BMI >30 kg/m²
Plus any one of:
- Patient was consulted about PAP use and declined
- Patient is unable to tolerate PAP therapy
- Patient is actively using PAP and will continue to use PAP
Reauthorization
All of:
- Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
- Patient continues to meet initial criteria 1–6 (age, no diabetes/A1C, OSA attestation, PAP status, lifestyle interventions, no combination GLP-1)
- Documentation of positive clinical response (e.g., weight loss, fewer AHIs per hour, or improved systolic blood pressure)