Medicare AdvantagePrior AuthHigh impact
Zepbound® (tirzepatide) (Revised)
Humana·Sleep Medicine, Pulmonology, Bariatric Surgery +1 more·Medicare Advantage
Effective date
Jan 20, 2025
We identified it
Jul 23, 2026
Summary
Humana Medicare Advantage now covers Zepbound (tirzepatide) for moderate to severe obstructive sleep apnea (OSA) in obese adults as of January 20, 2025. This is a NEW indication requiring prior authorization with specific clinical criteria including BMI ≥30, AHI/REI ≥15, and documented lifestyle modifications. Patients with type 1 or type 2 diabetes are excluded from coverage under this indication.
Action Required
By January 20, 2025: Billing team must implement prior authorization requirement for Zepbound (tirzepatide) claims under Humana Medicare Advantage for OSA indication. Update billing system to route these claims through preauthorization workflow and require providers to submit: (1) diagnosis of moderate-to-severe OSA, (2) member BMI ≥30 kg/m², (3) baseline AHI ≥15 or REI ≥15 from PSG or HSAT documentation, and (4) provider attestation of concurrent lifestyle modifications. Add exclusion rule to deny or route for manual review any claims for members with type 1 or type 2 diabetes diagnosis. Update encounter forms and provider communication materials to include OSA as new billable indication. Clinical staff must verify member meets all four criteria before claim submission. Without prior authorization, claims will be denied. Reference Humana PAL portal at www.humana.com/PAL for medical billing coding requirements.