Medicare AdvantagePrior AuthHigh impact
Zepbound® (tirzepatide) (Revised)
Humana·Sleep Medicine, Pulmonology, Bariatric Surgery +2 more·Medicare Advantage
Effective date
Jan 20, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Zepbound (tirzepatide) to cover a NEW indication: moderate to severe obstructive sleep apnea (OSA) in adults with obesity. Previously, Zepbound was only approved for weight loss; this expansion requires prior authorization based on specific OSA diagnostic criteria (AHI/REI ≥15, BMI ≥30, documented lifestyle modifications). Billing teams must implement prior auth requirements for all Zepbound claims under this new OSA indication effective immediately.
Action Required
REQUIREMENTS: By January 20, 2025 (retroactively): (1) Billing team must update claim submission system to trigger MANDATORY PRIOR AUTHORIZATION for all Zepbound (tirzepatide) claims with OSA (ICD-10: G47.30, G47.31, G47.32, G47.33, G47.34, G47.35, G47.36, G47.37) as primary/secondary diagnosis. (2) Prior auth verification workflow must confirm ALL FOUR clinical criteria are met before claim submission: member has moderate-to-severe OSA diagnosis, BMI ≥30 kg/m², AHI ≥15 on PSG or REI ≥15 on HSAT, and provider attestation of concurrent lifestyle modifications. (3) Update claim denial protocols—HCPCS codes J3490 and J3285 (tirzepatide) without prior auth approval will be DENIED for OSA indication. (4) Providers and clinical staff must be notified immediately: ALL Zepbound prescriptions for OSA require prior auth submission with polysomnogram or home sleep apnea test results attached. (5) Billing team: Create tracking mechanism to distinguish Zepbound claims by indication (obesity vs. OSA) since OSA now requires prior auth but obesity indication may have different requirements. (6) Document in EMR/billing software: Humana Revision Date 8/27/2025 confirms this is the CURRENT policy version—discard any older Zepbound policies. Failure to obtain prior authorization will result in claim denials and possible patient billing liability.