Ambetter (Centene marketplace) prior authorization letter for Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication).

The letter (copy and edit)

Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data before sending. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Ambetter (Centene marketplace)
Prior Authorization Department
Submitted via: Ambetter provider portal, CoverMyMeds or fax 1-866-685-8664

Re: Prior Authorization Request, Zepbound (tirzepatide)
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Group number: [Group number if applicable]
Prescriber: [Prescriber full name, NPI, DEA]
Prescriber contact: [Phone, fax, email]

To the Ambetter (Centene marketplace) Prior Authorization Reviewer,

I am the treating clinician for [Patient name]. I am writing to request prior authorization for Zepbound (tirzepatide) for treatment of Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication) (ICD-10: G47.33).

Clinical justification

FDA approved Zepbound (tirzepatide) for the treatment of moderate-to-severe obstructive sleep apnea in adults with obesity in December 2024, based on the SURMOUNT-OSA trial program. SURMOUNT-OSA enrolled adults with moderate-to-severe OSA (AHI greater than or equal to 15 events per hour) and BMI greater than or equal to 30. At week 52, Zepbound reduced the apnea-hypopnea index by 25 to 29 events per hour versus 5 events per hour for placebo, with approximately 43 to 52 percent of treated patients achieving disease resolution (AHI less than 5 or AHI 5 to 14 with no daytime symptoms). This is the first GLP-1 indication for OSA and is a Medicare-eligible indication unlike pure obesity.

Patient-specific findings

  - [Insert current measurements: weight, height, BMI, blood pressure]
  - [Insert relevant lab values with dates: A1c, lipid panel, kidney function]
  - [Insert documentation of comorbidities with ICD-10]
  - [Insert documentation of prior treatment history, including any prior GLP-1 trials, anti-obesity medication trials or lifestyle intervention]

Criteria met per Ambetter (Centene marketplace) policy

This request meets the criteria set out in Ambetter Clinical Policy CP.PMN.99, GLP-1 Receptor Agonists for Weight Management:

  - OSA diagnosed by polysomnography or home sleep apnea test with AHI greater than or equal to 15 (moderate to severe)
  - BMI greater than or equal to 30
  - Documentation of CPAP intolerance, non-adherence or patient preference (some plans require CPAP failure first; the FDA label does not require it)
  - Sleep medicine specialist involvement if the plan requires it
  - Most recent sleep study report attached

Supporting evidence

The clinical case for Zepbound (tirzepatide) in this indication is supported by the following registration trials and outcomes data:

  - SURMOUNT-OSA Study 1 (Zepbound in OSA patients on PAP therapy)
  - SURMOUNT-OSA Study 2 (Zepbound in OSA patients not on PAP therapy)

Plan-specific note

Ambetter is the ACA marketplace product from Centene-affiliated plans (operates in 25+ states under various local brands). Coverage of Wegovy and Zepbound for obesity requires BMI greater than or equal to 30 (or 27 with comorbidity), six months of documented lifestyle intervention and step therapy through phentermine or orlistat. Bronze and Silver tier plans frequently exclude anti-obesity medications from the formulary entirely; check your specific tier and state. Express Scripts is the PBM.

Requested action

I am requesting prior authorization for Zepbound (tirzepatide) at the [insert starting dose] starting dose, with planned titration per FDA labeling. I am also requesting that this authorization be granted for a continuous 12-month period subject to documented clinical response, per standard formulary practice.

If additional information is required, please contact me directly at [Prescriber phone] or [Prescriber email]. I am available to discuss this case with your medical director if helpful.

Thank you for your attention to this request.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Current vital signs and BMI calculation
  - Most recent relevant labs
  - Documentation of comorbidities
  - Documentation of prior treatment trials
  - Sleep study report (if OSA indication)
  - Cardiac history documentation (if CV indication)

Clinical rationale for this indication

FDA approved Zepbound (tirzepatide) for the treatment of moderate-to-severe obstructive sleep apnea in adults with obesity in December 2024, based on the SURMOUNT-OSA trial program. SURMOUNT-OSA enrolled adults with moderate-to-severe OSA (AHI greater than or equal to 15 events per hour) and BMI greater than or equal to 30. At week 52, Zepbound reduced the apnea-hypopnea index by 25 to 29 events per hour versus 5 events per hour for placebo, with approximately 43 to 52 percent of treated patients achieving disease resolution (AHI less than 5 or AHI 5 to 14 with no daytime symptoms). This is the first GLP-1 indication for OSA and is a Medicare-eligible indication unlike pure obesity.

ICD-10 codes to attach

• G47.33

Criteria checklist (what to attach with the letter)

1. OSA diagnosed by polysomnography or home sleep apnea test with AHI greater than or equal to 15 (moderate to severe)
2. BMI greater than or equal to 30
3. Documentation of CPAP intolerance, non-adherence or patient preference (some plans require CPAP failure first; the FDA label does not require it)
4. Sleep medicine specialist involvement if the plan requires it
5. Most recent sleep study report attached

Supporting trials and evidence

• SURMOUNT-OSA Study 1 (Zepbound in OSA patients on PAP therapy)
• SURMOUNT-OSA Study 2 (Zepbound in OSA patients not on PAP therapy)

The denial reasons to preempt

Most denials of this combination cite one of the reasons below. Address each one in the patient-specific findings section before you send. If the plan denies anyway, the appeal letter cites the same evidence with the denial reason added in the opening paragraph.

• Sleep study is more than three years old
• AHI documented is below 15 (mild OSA, not the SURMOUNT-OSA enrollment threshold)
• Patient has not been counseled on PAP therapy first on plans that require step therapy

If you have not picked a program yet

The PA path is faster when your prescriber is already familiar with your insurance plan and runs the authorization regularly. Programs in our chart that actively run prior authorization for Zepbound:

• PlushCare · commercial and Medicare PA experience
• Form Health · obesity-medicine specialty, high PA success rate
• Knownwell · cardiometabolic focus, all major PBMs
• Calibrate · insurance-focused, employer-friendly

Other indications under Ambetter (Centene marketplace)

If this indication is not the right fit, try a different qualifying indication under the same plan:

Same indication, other plans

Same Obstructive sleep apnea (Zepbound SURMOUNT-OSA indication) indication, different plan-specific letter templates if your insurance is not Ambetter (Centene marketplace):

Disclaimer

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact