Criteria-Based Consultation Prescribing Program - Kaiser Permanente Northwest Region Coverage Criteria - tirzepatide (Zepbound)

Oct 12, 2026

Uploaded by Connor

Coverage criteria for tirzepatide (Zepbound) under Kaiser Permanente Northwest Region’s prescription drug benefit. The document specifies that coverage is limited to eligible Kaiser members with coverage for weight-loss medications and outlines 12-month non-formulary clinical review requirements for chronic weight management, obstructive sleep apnea initiation, and adults with type 2 diabetes mellitus. It details contraindication exclusions, body weight/BMI documentation timing, lifestyle modification expectations, quantity limits, and required prior medication failures or trials, including semaglutide step-down after a minimum 6-month trial.

LanguageEnglish

CategoryGeneral

FormatPDF

Pages7

Reading Time3 min

AccessFree to download

Criteria-Based Consultation Prescribing Program

Kaiser Permanente Northwest Region: Criteria for Coverage (tirzepatide - Zepbound)

Initiation Criteria: Chronic Weight Management (Non-Formulary)

Initiation Criteria: Obstructive Sleep Apnea (OSA)

Initiation Criteria: Type 2 Diabetes Mellitus

Criteria-Based Consultation Prescribing Program KAISER PERMANENTE NORTHWEST REGION CRITERIA FOR COVERAGE tirzepatide (Zepbound) Notes: • Zepbound is covered under the prescription drug benefit for weight loss ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss. Others pay member cash price. • Contact Pharmacy Services in your home region to confirm your benefits for weight loss medications. • Quantity Limits: Yes • ^ Adequate trial is defined as a 3-month treatment duration • * Intolerance excludes adverse drug reactions that are expected, mild in nature, resolve with continued treatment, and do not require medication discontinuation Non-Formulary tirzepatide (Zepbound) requires a clinical review. Appropriateness of therapy will be based on the following criteria: Initiation (new start) criteria for adult patients for chronic weight management: Nonformulary tirzepatide (Zepbound) will be covered on the prescription drug benefit for 12 months when the following criteria are met: • Patient has a prescription drug insurance benefit that covers medications used to lose weight; AND • No personal or family history of medullary thyroid carcinoma (MTC) or Multi Endocrine Neoplasia syndrome type 2 (MEN 2); AND • Diagnosis for chronic weight management; AND • Patient is 18 years of age or older; AND • Patient’s current weight and BMI has been documented within the last 30 days approximately; AND • Patient is actively making lifestyle modification (diet and/or exercise) or have an active behavioral health referral to assist with lifestyle modification; AND • BMI greater than or equal to 30 kg/m2 or BMI greater than or equal to 27 kg/m2 AND has at least one of the following comorbid conditions documented: o Hypertension o Diabetes o Hyperlipidemia o Pre-Diabetes o Established CV disease or stroke o Congestive heart failure o Chronic kidney disease Criteria-Based Consultation Prescribing Program KAISER PERMANENTE NORTHWEST REGION CRITERIA FOR COVERAGE tirzepatide (Zepbound) o Non-alcoholic fatty liver disease o Obstructive sleep apnea o Osteoarthritis in weight-bearing joints o Polycystic ovarian syndrome -AND- • Patient has failed an adequate trial^ to at least two of the following medications or medication combination therapies , or patient has an allergy, intolerance , or contraindication to all the following therapies: o phentermine o diethylpropion o topiramate o phentermine + topiramate or phentermine/topiramate (Qsymia) o naltrexone + bupropion or naltrexone/bupropion (Contrave) -AND- • Patient has then failed a minimum 6-month trial of semaglutide (Ozempic/Wegovy) followed by a bariatric medicine chart review to determine necessity to switch to tirzepatide (Zepbound) or has an allergy, intolerance, or contraindication tosemaglutide (Ozempic/Wegovy) Initiation (new start) criteria for obstructive sleep apnea (OSA) : Non-formulary tirzepatide (Zepbound) will be covered on the prescription drug benefit for 12 months when the following criteria are met: • No personal or family history of medullary thyroid carcinoma (MTC) or Multi Endocrine Neoplasia syndrome type 2 (MEN 2); AND • Patient does not have central or complex apnea; AND • Patient has had a sleep study within the last 5 years and they have not lost more than 5% body weight since the time of the study (study weight is +/-3 months from time of study); AND • Diagnosis for severe sleep apnea (AHI 30 or greater); AND • Patient is 18 years of age or older; AND • Patient’s current weight and BMI has been documented within the last 30 days approximately; AND • Patient is actively making lifestyle modification (diet and/or exercise) or have an active behavioral health referral to assist with lifestyle modification; AND • BMI greater than or equal to 30 kg/m2 ; AND Criteria-Based Consultation Prescribing Program KAISER PERMANENTE NORTHWEST REGION C

FAQs

What does the document say about Zepbound coverage under the Kaiser Permanente Northwest prescription drug benefit?

Zepbound is covered only for Kaiser Northwest members whose prescription drug benefit includes coverage for medications used to treat weight loss. Other members pay the cash price unless they confirm benefits with Pharmacy Services in their home region.

What is required for non-formulary tirzepatide (Zepbound) to be covered for chronic weight management?

Coverage for 12 months requires an active prescription drug insurance benefit that covers weight-loss medications, no personal or family history of MTC or MEN 2, a diagnosis of chronic weight management, age 18+, documented weight/BMI within ~30 days, lifestyle modification or a behavioral health referral, BMI thresholds (≥30 or ≥27 with comorbidities), and failure of an adequate trial of at least two specified therapies plus a subsequent semaglutide (Ozempic/Wegovy) step involving a minimum 6-month trial and chart review.

What additional initiation criteria apply when the indication is obstructive sleep apnea (OSA)?

The document requires no MTC/MEN 2 history and no central or complex apnea, a sleep study within the last 5 years without >5% weight loss since the study, diagnosis of severe sleep apnea (AHI ≥30), age 18+, documented weight/BMI within ~30 days, active lifestyle modification or behavioral health referral, and BMI ≥30 kg/m2.

Oct 12, 2026

Uploaded by Connor