[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-563972-105":53,"doc-detail-563972-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","clinical-policy-tirzepatide-zepbound-nepmn298","Clinical Policy - Tirzepatide (Zepbound) - NE.PMN.298","","Clinical Policy NE.PMN.298 defines coverage criteria for tirzepatide (Zepbound) under Nebraska Total Care Medicaid. It specifies FDA-indicated uses with limits, including weight management with a reduced-calorie diet and increased physical activity, and moderate to severe obstructive sleep apnea in adults with obesity. The policy requires documented eligibility, detailed initial-approval conditions (diagnostic thresholds, supervised weight management, adherence to PAP/oral appliance, and contraindication exclusions), and ongoing therapy criteria with response evidence.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/clinical-policy-tirzepatide-zepbound-nepmn298/563972/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/clinical-policy-tirzepatide-zepbound-nepmn298/563972.png","ImageObject",442,249,{"name":88,"@type":89},"Rhys","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-10-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What conditions must be met for initial approval of Zepbound for obstructive sleep apnea?","Question",{"text":109,"@type":110},"Approval requires documented moderate to severe OSA on polysomnography with specified AHI/RDI/REI thresholds, a sleep specialist prescription, age ≥18, BMI ≥30, completion of a supervised 6-month weight management program, and provider attestations including adherence to sleep positioning and PAP or oral appliance therapy.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When is Zepbound not recommended or excluded under this policy?",{"text":114,"@type":110},"The policy limits use by not recommending coadministration with other tirzepatide-containing products or any GLP-1 receptor agonist. It also includes exclusions such as diabetes mellitus or HgA1c ≥6.5%, certain comorbid conditions (e.g., NYHA Class IV heart failure, severe gastroparesis), and pregnancy or lack of effective contraception.",{"name":116,"@type":107,"acceptedAnswer":117},"What evidence is required to continue therapy for obstructive sleep apnea?",{"text":118,"@type":110},"Continued therapy requires the member is actively receiving or previously met initial criteria, a sleep specialist prescription, and positive response to therapy demonstrated by AHI, RDI, or REI reduction from baseline, along with ongoing exclusion checks and no concurrent use with other specified agents.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},563972,1792107089,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Clinical Policy: Tirzepatide (Zepbound)  \nReference Number: NE.PMN.298  \nEffective Date: 7.1.25  \nLast Review Date: 6.4.26  \nLine of Business: Medicaid  \nCoding Implications Revision Log  \nSee Important Reminder at the end of this policy for important regulatory and legal information.  \nDescription  \nTirzepatide (Zepbound®) is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist.  \nFDA Approved Indication(s)  \nZepbound is indicated in combination with a reduced-calorie diet and increased physical activity:  \n• 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  \n• To treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity  \nLimitation(s) of use: Coadministration with other tirzepatide-containing products or any GLP-1 receptor agonist is not recommended.  \nPolicy/Criteria  \nProvider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.  \nIt is the policy of Nebraska Total Care that Zepbound is medically necessary when the following criteria are met:  \nI. Initial Approval Criteria  \nA. Obstructive Sleep Apnea (must meet all):  \n1. Diagnosis of moderate to severe OSA with polysomnography (PSG) evidence of oneof the following (a, b, or c) :  \na. Apnea-Hypopnea Index (AHI) ≥ 15 respiratory events per hour;  \nb. Respiratory Disturbance Index (RDI) ≥ 15;  \nc. Respiratory Event Index (REI) ≥ 15;  \n2. Medication is prescribed by or in consultation with a sleep specialist;  \n3. Age ≥ 18 years;  \n4. Body mass index (BMI) ≥ 30 kg/m2 ;  \n5. The member has completed a weight management program medically supervised by a physician, nurse practitioner, or physician assistant and counseling for at least 6 months that includes all of the following (a, b, c, d and e):  \na. Behavioral modification;  \nb. Reduced calorie diet;  \nc. Increased physical activity;  \nd. Counseling to avoid sleeping in the supine position;  \ne. Counseling to avoid alcohol and sedatives before bedtime  \n6. The provider attests that the member is currently on and will continue (must meet all):  \na. Behavioral modification;  \nb. Reduced calorie diet;  \nc. Increased physical activity, if possible;  \nd. Compliance with sleep positioning;  \ne. Compliance with no alcohol or sedatives before bedtime;  \nf. Adherence to the prescribed PAP treatment (defined as > 4 hours of use per night for> 70 percent of nights for 2 or more months)  \ng. Adherence to the prescribed oral appliance treatment (defined as > 4 hours of use per night for> 70 percent of nights for 2 or more months) as applicable (see Appendix E for examples of oral appliances used in OSA);  \n7. Member does not have a diagnosis of diabetes mellitus;  \n8. Member does not have an HgA1c ≥ 6.5% ;  \n9. Member meets one of the following (a or b or c):  \na. Failure to achieve therapeutic goals on positive airway pressure (PAP) treatment despite optimization;  \nb. Intolerance to PAP treatment;  \nc. Is not a candidate for PAP treatment;  \n10. Member meets one of the following (a or b or c):  \na. Failure to achieve therapeutic goals on an oral appliance treatment despite optimization (see Appendix E for examples of oral appliances used in OSA);  \nb. Intolerance to oral appliance treatment;  \nc. Is not a candidate for oral appliance treatment;  \n11. The member does not have any of the following (a, b and c):  \na. Planned surgery for sleep apnea or obesity  \nb. Significant craniofacial abnormalities  \nc. A diagnosis of central or mixed sleep apnea  \n12. The provider attests that the member does not have any of the following (must meet all):  \na. NYHA Class IV Heart failure;  \nb. Impaired renal function (eGFR \u003C 30 mL/min/1 .73m2) ;  \nc. History of chronic pancreatitis or presence of acute or chronic pancreatitis;  \nd. Personal or ","cbCailfl9fDliS5H","https://ap.wps.com/l/cbCailfl9fDliS5H","pdf",332942,8,"English","# Policy/Criteria\n## Initial Approval Criteria\n### Obstructive Sleep Apnea\n### Weight Management\n## Continued Therapy\n### Obstructive Sleep Apnea","[{\"question\":\"What conditions must be met for initial approval of Zepbound for obstructive sleep apnea?\",\"answer\":\"Approval requires documented moderate to severe OSA on polysomnography with specified AHI/RDI/REI thresholds, a sleep specialist prescription, age ≥18, BMI ≥30, completion of a supervised 6-month weight management program, and provider attestations including adherence to sleep positioning and PAP or oral appliance therapy.\"},{\"question\":\"When is Zepbound not recommended or excluded under this policy?\",\"answer\":\"The policy limits use by not recommending coadministration with other tirzepatide-containing products or any GLP-1 receptor agonist. It also includes exclusions such as diabetes mellitus or HgA1c ≥6.5%, certain comorbid conditions (e.g., NYHA Class IV heart failure, severe gastroparesis), and pregnancy or lack of effective contraception.\"},{\"question\":\"What evidence is required to continue therapy for obstructive sleep apnea?\",\"answer\":\"Continued therapy requires the member is actively receiving or previously met initial criteria, a sleep specialist prescription, and positive response to therapy demonstrated by AHI, RDI, or REI reduction from baseline, along with ongoing exclusion checks and no concurrent use with other specified agents.\"}]","Clinical Policy - Tirzepatide (Zepbound) - NE.PMN.298 | PDF",1791839630]