Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan
Subject: Zepbound PA with Limit 6192-C 08-2026 v3
Policy:
Drugs that are listed in the following table include both brand and generic and all dosage forms and strengths except the vials, which are covered under the LillyDirect manufacturer program. Over-the-counter (OTC) products are not included unless otherwise stated.
Brand Name
Generic Name
Zepbound
tirzepatide
Indications
FDA-approved Indications
Zepbound is indicated in combination with a reduced-calorie diet and increased physical activity:
·to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.
·to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Limitations of Use
Zepbound contains tirzepatide. Coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended.
Coverage Criteria
Obstructive Sleep Apnea
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to treat moderate to severe obstructive sleep apnea (OSA) in an adult with obesity when ALL of the following criteria are met:
·The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device. [ACTION REQUIRED: Documentation is required for approval.]
·The patient has a baseline body mass index (BMI) greater than or equal to 30 kg/m2. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term in an adult when ALL of the following criteria are met:
·The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.
·The patient meets ONE of the following:
§The patient has a baseline body mass index (BMI) greater than or equal to 30 kg/m2. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
§The patient has a baseline BMI greater than or equal to 27 kg/m2. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.] In addition, the following criteria is met:
·The patient has at least ONE of the following weight-related comorbid conditions: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
Continuation of Therapy
Obstructive Sleep Apnea
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to treat moderate to severe obstructive sleep apnea (OSA) in an adult with obesity when ALL of the following criteria are met:
·The patient has an established diagnosis of moderate to severe OSA with an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device. [ACTION REQUIRED: Documentation is required for approval.]
·The patient has achieved or maintained a positive response to treatment from baseline, evidenced by a decrease in OSA symptoms.
·The patient is being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability.
Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term
Authorization may be granted when the requested drug will be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term in an adult when ALL of the following criteria are met:
·The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose.
·The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss. [ACTION REQUIRED: Documentation is required for approval.]
·The patient meets ONE of the following:
§The patient had a baseline body mass index (BMI) greater than or equal to 30 kg/m2 at the start of drug therapy for weight loss. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
§The patient had a baseline BMI greater than or equal to 27 kg/m2 at the start of drug therapy for weight loss. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.] In addition, the following criteria is met:
·The patient has at least ONE of the following weight-related comorbid conditions at the start of drug therapy for weight loss: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip. [NOTE: If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy.] [ACTION REQUIRED: Documentation is required for approval.]
Quantity Limits Apply
The duration of 21 days is used for a 28-day fill period and 63 days is used for an 84-day fill period to allow time for refill processing.
§Reduction in excess body weight, maintenance of weight reduction long term: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months
Place of Service:
Outpatient
The above policy is based on the following references:
References
1.Zepbound [package insert]. Indianapolis, IN: Lilly USA, LLC; April 2026.
2.Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2026. https://online.lexi.com. Accessed June 12, 2026.
3.Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 06/12/2026).
4.Jensen MD, Ryan DH, Apovian DM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Circulation. 2014;129(suppl 2):S102-S138.
5.Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015;100(2):342–362.
6.Malhorta A, Grunstein RR, Fietze I, et al. Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity. New Engl J Med. 2024;391:1193-1205.
7.Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(3):479-504.
Document History
Written by: UM Development (MRS)
Date Written: 11/2023
Revised: 04/2024 (added Zepbound single-dose vials to QL chart), 07/2024 (no clinical changes), 10/2024 (aligned coverage criteria verbiage with updated label, updated target drug disclaimer to exclude vials), 12/2024 (added OSA per updated label), 01/2025 (amended coverage for OSA), 02/2025 (updated disclaimer); KEJ 07/2025 (off cycle-updated disclaimer); MRS 07/2025 (updated dosage criteria for COT for OSA); KEJ 01/2026 (added Zepbound KwikPen); SN 07/2026 (added baseline BMI requirement to COT), 08/2026 (updated Zepbound OSA to baseline BMI requirement); KEJ/SN 09/2026 (updated comorbid conditions to a list)
Quantity for Approval 4 pre-filled single-dose pens or 1 single-patient-use KwikPen/21 days, 12 pre-filled single-dose pens or 3 single-patient-use KwikPens/63 days
Set 1 – Weight Continuation, BMI 27-30 + risk factor
Duration of Approval 12 Months
Yes to question(s)
No to question(s)
1, 2, 4, 5, 9
3, 10
Set 2 – Weight Continuation, BMI 30-35
Duration of Approval 12 Months
Yes to question(s)
No to question(s)
1, 2, 6, 9
3, 4, 10
Set 3 – Weight Continuation, BMI 35-40
Duration of Approval 12 Months
Yes to question(s)
No to question(s)
1, 2, 7, 9
3, 4, 6, 10
Set 4 – Weight Continuation, BMI > 40
Duration of Approval 12 Months
Yes to question(s)
No to question(s)
1, 2, 8, 9
3, 4, 6, 7, 10
Set 5 – Weight Initial, BMI 27-30 + risk factor
Duration of Approval 8 Months
Yes to question(s)
No to question(s)
1, 11, 13, 14
2, 12, 18
Set 6 – Weight Initial, BMI 30-35
Duration of Approval 8 Months
Yes to question(s)
No to question(s)
1, 11, 15
2, 12, 13, 18
Set 7 – Weight Initial, BMI 35-40
Duration of Approval 8 Months
Yes to question(s)
No to question(s)
1, 11, 16
2, 12, 13, 15, 18
Set 8 – Weight Initial, BMI > 40
Duration of Approval 8 Months
Yes to question(s)
No to question(s)
1, 11, 17
2, 12, 13, 15, 16, 18
Set 9 – OSA Continuation
Duration of Approval 12 Months
Yes to question(s)
No to question(s)
19, 20, 21, 22, 23
1, 24
Set 10 – OSA Initial
Duration of Approval 6 Months
Yes to question(s)
No to question(s)
19, 20, 25
1, 21, 26
CRITERIA FOR APPROVAL
1
Will the requested drug be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term in an adult? [If Yes, then go to 2. If No, then go to 19.]
Yes
No
2
Has the patient completed at least 3 months of therapy with the requested drug at a stable maintenance dose? [If the patient is transitioning from another drug therapy for weight loss, please answer no and proceed.] [If Yes, then go to 3. If No, then go to 11.]
Yes
No
3
Did the patient have a baseline body mass index (BMI) of less than 27 kg/m2 at the start of drug therapy for weight loss? [If the patient is transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] [If Yes, then no further questions. If No, then go to 4.]
Yes
No
4
Did the patient have a baseline body mass index (BMI) of 27 kg/m2 to less than 30kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 5. If No, then go to 6.]
Yes
No
5
Did the patient have at least ONE of the following weight-related comorbid conditions at the start of drug therapy for weight loss: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip? [If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that indicate the patient's weight-related comorbid condition(s). (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 9. If No, then no further questions.]
Yes
No
6
Did the patient have a baseline body mass index (BMI) of 30 kg/m2 to less than 35 kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 9. If No, then go to 7.]
Yes
No
7
Did the patient have a baseline body mass index (BMI) of 35 kg/m2 to less than 40 kg/m2 at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 9. If No, then go to 8.]
Yes
No
8
Did the patient have a baseline body mass index (BMI) of 40 kg/m2 or greater at the start of drug therapy for weight loss? [If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 9. If No, then no further questions.]
Yes
No
9
Has the patient lost at least 5 percent of baseline body weight OR has the patient continued to maintain their initial 5 percent weight loss? ACTION REQUIRED: If yes, then documentation is required for approval. Document the patient's weight prior to starting drug therapy for weight loss and the patient's current weight, including the dates the weights were taken: ____________________________ [If Yes, then go to 10. If No, then no further questions.]
Yes
No
10
Does the patient require MORE than the plan allowance of 4 pre-filled single-dose pens or 1 single-patient-use KwikPen of Zepbound (tirzepatide) per 28 days? [If Yes, then no further questions. If No, then no further questions.]
Technician Note & RPh Note: RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.
Yes
No
11
Has the patient participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy? [If Yes, then go to 12. If No, then no further questions.]
Yes
No
12
Does the patient have a baseline body mass index (BMI) of less than 27 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] [If Yes, then no further questions. If No, then go to 13.]
Yes
No
13
Does the patient have a baseline body mass index (BMI) of 27 kg/m2 to less than 30 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 14. If No, then go to 15.]
Yes
No
14
Does the patient have at least ONE of the following weight-related comorbid conditions: hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated steatotic liver disease (MASLD), prediabetes, chronic kidney disease stage 2 or higher, osteoarthritis of the knee and/or hip? [If the patient is transitioning from another drug therapy for weight loss, please consider their weight-related comorbid condition(s) at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that indicate the patient's weight-related comorbid condition(s). (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 18. If No, then no further questions.]
Yes
No
15
Does the patient have a baseline body mass index (BMI) of 30 kg/m2 to less than 35 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 18. If No, then go to 16.]
Yes
No
16
Does the patient have a baseline body mass index (BMI) of 35 kg/m2 to less than 40 kg/m2? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 18. If No, then go to 17.]
Yes
No
17
Does the patient have a baseline body mass index (BMI) of 40 kg/m2 or greater? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 18. If No, then no further questions.]
Yes
No
18
Does the patient require MORE than the plan allowance of 4 pre-filled single-dose pens or 1 single-patient-use KwikPen of Zepbound (tirzepatide) per 28 days? [If Yes, then no further questions. If No, then no further questions.]
Technician Note & RPh Note: RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.
Yes
No
19
Will the requested drug be used with a reduced-calorie diet AND increased physical activity to treat moderate to severe obstructive sleep apnea (OSA) in an adult with obesity? [If Yes, then go to 20. If No, then no further questions.]
Yes
No
20
Does the patient have an established diagnosis of moderate to severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT) with a technically adequate device? ACTION REQUIRED: If yes, then prescriber MUST submit chart notes showing the patient's AHI on PSG or HSAT. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 21. If No, then no further questions.]
Yes
No
21
Is this request for continuation of therapy? [If Yes, then go to 22. If No, then go to 25.]
Yes
No
22
Has the patient achieved or maintained a positive response to treatment from baseline, evidenced by a decrease in obstructive sleep apnea (OSA) symptoms? [If Yes, then go to 23. If No, then no further questions.]
Yes
No
23
Is the patient being treated with a maintenance dosage of the requested drug which is based on individual treatment response and tolerability? [If Yes, then go to 24. If No, then no further questions.]
Yes
No
24
Does the patient require MORE than the plan allowance of 4 pre-filled single-dose pens or 1 single-patient-use KwikPen of Zepbound (tirzepatide) per 28 days? [If Yes, then no further questions. If No, then no further questions.]
Technician Note & RPh Note: RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.
Yes
No
25
Does the patient have a baseline body mass index (BMI) of 30 kg/m2 or greater? [If the patient is transitioning from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy when answering this question.] ACTION REQUIRED: If yes, then prescriber MUST submit chart notes that show the patient's baseline BMI. (ACTION REQUIRED: Submit supporting documentation.) [If Yes, then go to 26. If No, then no further questions.]
Yes
No
26
Does the patient require MORE than the plan allowance of 4 pre-filled single-dose pens or 1 single-patient-use KwikPen of Zepbound (tirzepatide) per 28 days? [If Yes, then no further questions. If No, then no further questions.]
Technician Note & RPh Note: RPh Note: If yes, then deny and enter a partial approval per Quantity Limit Chart.
Yes
No
Mapping Instructions
Yes
No
DENIAL REASONS
1.
Go to 2
Go to 19
2.
Go to 3
Go to 11
3.
Deny
Go to 4
Your plan only covers this drug when it is used for certain health conditions. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your plan does not cover this drug for your health condition that your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Diagnosis, Weight Loss]
4.
Go to 5
Go to 6
5.
Go to 9
Deny
Your plan only covers this drug when it is used for certain health conditions and when records with your health condition(s) are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions at the start of drug therapy for weight loss. Your records must be provided and must show what your doctor told us.We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show what your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Your plan only covers this drug when it is used for certain health conditions, and when records with your initial body mass index (BMI) at the start of drug therapy for weight loss are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions, and when records with your initial body mass index (BMI) are sent to us. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show the initial body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Your plan only covers this drug when you experience benefits from taking the drug and when your results from taking the drug are sent to us.Your doctor needs to send us all of the following: A) Your weight prior to starting weight loss drug therapy, B) Your weight now, and C) The dates your weights were taken. We have denied your request because you did not have good outcomes from the drug or because we did not receive all of your results.We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Continuation: Efficacy, Positive Response, Stable or Not worsening, Lab/test with documentation]
10.
Deny
Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.
We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers (4 pre-filled single-dose pens or 1 single-patient-use KwikPen per 28 days). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Quantity, Exceeds max limit, Partial denial]
11.
Go to 12
Deny
Your plan only covers this drug if you have been in a comprehensive weight management program for at least 6 months before starting this drug. We have denied your request because you have not been taking part in a comprehensive weight management program for at least 6 months. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: No comprehensive weight management program]
12.
Deny
Go to 13
Your plan only covers this drug when it is used for certain health conditions. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your plan does not cover this drug for your health condition that your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Diagnosis, Weight Loss]
13.
Go to 14
Go to 15
14.
Go to 18
Deny
Your plan only covers this drug when it is used for certain health conditions and when records with your health condition(s) are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions. Your records must be provided and must show what your doctor told us.We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show what your doctor told us you have. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Your plan only covers this drug when it is used for certain health conditions, and when records with your initial body mass index (BMI) at the start of weight loss are sent to us. Covered uses are when you have: A) An initial body mass index (BMI) of at least 30 kg/m2, or B) An initial BMI of 27 kg/m2 to less than 30 kg/m2 with one or more weight-related health conditions, and when records with your initial body mass index (BMI) are sent to us. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition that your doctor told us you have, we did not receive your records, or the records did not show the initial body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Approve, 8 Months, PA approved for 8 months. See Quantity Limit Chart.
We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers (4 pre-filled single-dose pens or 1 single-patient-use KwikPen per 28 days). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Quantity, Exceeds max limit, Partial denial]
19.
Go to 20
Deny
Your plan only covers this drug when it is used for certain health conditions as part of a healthy living plan supported by the FDA (United States Food and Drug Administration). Covered uses are to A) Decrease body weight in obese or overweight adults, B) Maintain weight loss long term in obese or overweight adults, and C) Treat moderate to severe obstructive sleep apnea (OSA) in obese adults. When using this drug for these health conditions, you must be on a low calorie diet and do physical activity. Your plan does not cover this drug for your health condition that your doctor told us you have, or you will not be on a low calorie diet and doing physical activity while taking this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Diagnosis, per indication]
20.
Go to 21
Deny
Your plan only covers this drug if you have moderate to severe obstructive sleep apnea (OSA) as shown by a sleep study, and when records showing you have moderate to severe obstructive sleep apnea (OSA) are sent to us. Your records must be provided and must show what your doctor tells us. We reviewed the information we had. We denied your request because we did not receive your records or the records did not show what your doctor has told us. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: OSA, Disease severity with documentation]
21.
Go to 22
Go to 25
22.
Go to 23
Deny
Your plan only covers this drug when you experience benefits from taking the drug. We have denied your request because you did not have good outcomes from the drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Your plan only continues to cover this drug when you are taking a maintenance dose of this drug. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: OSA, Maintenance Dosing]
24.
Deny
Approve, 12 Months, PA approved for 12 months. See Quantity Limit Chart.
We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers (4 pre-filled single-dose pens or 1 single-patient-use KwikPen per 28 days). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Quantity, Exceeds max limit, Partial denial]
25.
Go to 26
Deny
Your plan only covers this drug for obstructive sleep apnea (OSA) if your baseline body mass index (BMI) is 30 kg/m2 or higher and when records with your baseline body mass index (BMI) are sent to us. Your records must be provided and must show what your doctor tells us. We denied your request because your plan does not cover this drug for your health condition with the body mass index (BMI) your doctor told us you have, we did not receive your records, or the records did not show your baseline body mass index (BMI) your doctor told us. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: OSA, Exclusion for BMI with documentation]
26.
Deny
Approve, 6 Months, PA approved for 6 months. See Quantity Limit Chart.
We have denied your request because it is for more than the amount your plan covers (quantity limit). We reviewed the information we had. We have partially approved your request for this drug up to the amount your plan covers (4 pre-filled single-dose pens or 1 single-patient-use KwikPen per 28 days). Your request for more drug has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
[Short Description: Quantity, Exceeds max limit, Partial denial]
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
