[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-563970-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-563970-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","pa-zepbound-osa-medicaid-pharmacy-prior-authorizationstep-edit-request","PA Zepbound-OSA (Medicaid) - Pharmacy Prior Authorization/Step-Edit Request","","Sentara Community Plan Medicaid pharmacy prior authorization/step-edit request form for Zepbound (tirzepatide) for obstructive sleep apnea (OSA). The form instructs prescribers to sign and print name, provide complete member and prescriber details, and submit required drug, dosing, diagnosis, and documentation. Approval depends on meeting all listed clinical criteria for initial authorization and reauthorization, including CPAP trial failure or intolerance, OSA severity by AHI, BMI threshold, documented weight loss plan, and exclusion of contraindications and other GLP-1 use.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/pa-zepbound-osa-medicaid-pharmacy-prior-authorizationstep-edit-request/563970/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/pa-zepbound-osa-medicaid-pharmacy-prior-authorizationstep-edit-request/563970.png","ImageObject",442,249,{"name":42,"@type":43},"Mia  ","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-15","2026-10-12",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What must the prescribing physician do to submit this prior authorization request?","Question",{"text":62,"@type":63},"The prescribing physician must sign and clearly print their name on the request. Preprinted stamps are not valid.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What dosing schedule is specified for Zepbound for OSA?",{"text":67,"@type":63},"Starting dosage for all indications is 2.5 mg injected SC once weekly for 4 weeks. Maintenance for OSA is 10 mg or 15 mg injected SC once weekly.",{"name":69,"@type":60,"acceptedAnswer":70},"What documentation is required for initial authorization and what is the approval window?",{"text":71,"@type":63},"All criteria must be met with supporting documentation, including polysomnography within the last 12 months and a weight loss treatment plan within the past 6 months. Initial authorization is for 6 months.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},563970,1792107099,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":22,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","SENTARA COMMUNITY PLAN  \n(MEDICAID)  \nPHARMACY PRIOR AUTHORIZATION/STEP-EDIT REQUEST*  \nDirections: The prescribing physician must sign and clearly print name (preprinted stamps not valid) on this request. All other information may be filled in by office staff; fax to 1-800-750-9692. No additional phone calls will be necessary if all information (including phone and fax \\#s) on this form is correct. If the information provided is not  complete, correct, or legible, the authorization process can be delayed.  \nDrug Requested: Zepbound® (tirzepatide) for Obstructive Sleep Apnea (OSA)  \nMEMBER & PRESCRIBER INFORMATION: Authorization may be delayed if incomplete.  \nMember Name:   Member Sentara \\#:   Date ofBirth:   Prescriber Name:   Prescriber Signature:   Date:   Office Contact Name:    \nPhone Number: Fax Number:  \n__________________________________________ _____________________________  \nNPI \\#:    \nDRUG INFORMATION: Authorization may be delayed if incomplete.  \nDrug Name/Form/Strength:   Dosing Schedule:   Length of Therapy:   Diagnosis:   ICD Code, if applicable:   Weight (if applicable):   Date weight obtained:   Recommended Dosage for Obstructive Sleep Apnea:  \n• Starting dosage of Zepbound for all indications is 2.5 mg injected SC once weekly for 4 weeks.  \no The maintenance dosage for OSA is 10 mg or 15 mg injected SC once weekly  \no The maintenance dosage for weight reduction is 5 mg, 10 mg, or 15 mg, injected SC once weekly  \n\n| CLINICAL CRITERIA: Check below all that apply. All criteria must be met for approval. To support each line checked, all documentation, including lab results, diagnostics, and/or chart notes, must be provided or request may be denied. |\n| --- |\n| Initial Authorization: 6 months |\n\n􀂉 Member is 18 years of age or older  \n􀂉 The requesting provider is managing the member’s obstructive sleep apnea  \n(Continued on next page)  \nPA Zepbound-OSA (Medicaid)  \n(continued from previous page)  \n􀂉 Member has a diagnosis of moderate to severe obstructive sleep apnea (OSA) defined by an apneahypopnea index ≥ 15 events/hour confirmed by polysomnography  \n􀂉 Member is currently on or has tried, failed or unable to tolerate continuous positive airway pressure therapy (CPAP) (an adequate trial is defined as CPAP use for ≥ 4 hours per night on ≥ 70% of nights for two or more months)  \n􀂉 If unable to tolerate CPAP therapy, please explain the intolerance below:  \n__________________________________________________________________________________________________  \n__________________________________________________________________________________________________  \n􀂉 Member has a body mass index (BMI) of > 30kg/m2  \n􀂉 Member must have participated in a weight loss treatment plan (e.g. nutritional counseling, an exercise regimen, and calorie restricted/fat restricted diet) in the past 6 months and will continue to follow this treatment plan while taking an anti-obesity medication for obstructive sleep apnea  \n􀂉 Member does NOT have craniofacial abnormalities that may affect breathing  \n􀂉 Member does NOT have diagnosis of central or mixed sleep apnea or Cheyne-Stokes respiration  \n􀂉 Member is NOT using any other GLP-1 product  \n􀂉 Member does NOT have pancreatitis, acute suicidal behavior/ideation, gastroparesis or using prokinetic drugs (i.e metoclopramide), personal or family history of medullary thyroid cancer or multiple endocrine neoplasia 2 syndrome  \n􀂉 Documentation submitted:  \n􀂉 Polysomnography conducted within the last 12 months  \n􀂉 Weight loss treatment plan within the past 6 months  \nReauthorization: up to 12 months. Check below all that apply. All criteria must be met for approval. To support each line checked, all documentation, including lab results, diagnostics, and/or chart notes, must be provided or request may be denied.  \n􀂉 Member continues to meet the criteria  \n􀂉 Member is being treated with a maintenance dosage of the requested drug  \n􀂉 Documentation that the member has experienced improvement in OSA sym","cbCaicy4bSOw9285","https://ap.wps.com/l/cbCaicy4bSOw9285","pdf",242608,"English","# Pharmacy Prior Authorization/Step-Edit Request\n## Instructions and Submission Requirements\n## Drug and Member/Prescriber Information\n## Drug Information and Dosing Schedule\n## Clinical Criteria for Initial Authorization\n## Clinical Criteria for Reauthorization","[{\"question\":\"What must the prescribing physician do to submit this prior authorization request?\",\"answer\":\"The prescribing physician must sign and clearly print their name on the request. Preprinted stamps are not valid.\"},{\"question\":\"What dosing schedule is specified for Zepbound for OSA?\",\"answer\":\"Starting dosage for all indications is 2.5 mg injected SC once weekly for 4 weeks. Maintenance for OSA is 10 mg or 15 mg injected SC once weekly.\"},{\"question\":\"What documentation is required for initial authorization and what is the approval window?\",\"answer\":\"All criteria must be met with supporting documentation, including polysomnography within the last 12 months and a weight loss treatment plan within the past 6 months. Initial authorization is for 6 months.\"}]","PA Zepbound-OSA (Medicaid) - Pharmacy Prior Authorization/Step-Edit Request | PDF",1791839625]