Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI at or above the 95th percentile for age and sex
- A1C no higher than 6.5%
- 6 months of a documented diet and exercise program
- Prior trial of Contrave, orlistat, phentermine, and Qsymia for at least 3 months
- Prescribed by or in consultation with a specialist
- Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
- Lab results confirming eligibility
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
Initial Approval: Zepbound for Moderate-to-Severe OSA with Obesity
All of:
- Prescribed by or in consultation with a Pulmonologist or Sleep Medicine Physician
- Diagnosis of moderate to severe obstructive sleep apnea in an individual with obesity
- Age 18 years or older
- Apnea Hypopnea Index (AHI) greater than 15 events/hour on polysomnogram
- BMI >= 95th percentile (pediatric) OR BMI >= 30 kg/m2 (adult)
- No concomitant use with GLP-1 agonists (e.g., Ozempic, Rybelsus, Trulicity, Mounjaro)
- No FDA labeled contraindications (personal/family history of medullary thyroid carcinoma, MEN2, or prior serious hypersensitivity to GLP-1 receptor agonists)
- No diagnosis of diabetes mellitus type 1 or type 2, history of ketoacidosis, hyperosmolar state/coma, or HbA1c > 6.5%
- Not solely used for weight loss; must also be on appropriate therapy for OSA
- Using PAP therapy unless medically contraindicated
- Participating in a program supporting reduced calorie diet (>=500 kcal/day reduction) and physical activity (>=150 min/week)
- Failure, contraindication, or intolerance to THREE generic equivalents (if available) for at least 3 months each
- No severe gastrointestinal disease including severe gastroparesis, suicidal behavior or ideation, signs/symptoms of pancreatitis, gallbladder disease, or pregnancy
Plus any one of:
- Failure (trial >= 3 months) of at least ONE non-GLP-1 weight loss medication: Contrave, orlistat, phentermine, or Qsymia
- Contraindication to all listed non-GLP-1 weight loss medications
- Intolerance to all listed non-GLP-1 weight loss medications
Continuation/Renewal: Zepbound for OSA
All of:
- Continues to be seen by or in consultation with a Pulmonologist or Sleep Medicine Physician
- Improvement in Apnea Hypopnea Index over baseline
- Reduction of 5% or more in body weight from baseline
- Documented adherence to prescribed therapy regimen
- Continues reduced calorie diet (>=500 kcal/day reduction) and physical activity (>=150 min/week)
- Failure, contraindication, or intolerance with THREE generic equivalents (if available) for at least 3 months each
- No concomitant use with GLP-1 agonists
- No new contraindications or significant adverse drug effects (pancreatitis, severe hypersensitivity, acute kidney injury, severe GI disease, drug-induced immune mediated thrombocytopenia, acute gallbladder disease)
- No diagnosis of T1DM, T2DM, history of ketoacidosis, hyperosmolar state/coma, or HbA1c >= 6.5%
- Not solely used for weight loss; must also be on appropriate therapy for OSA
- Using PAP therapy unless medically contraindicated
- Not currently taking any other drugs causing severe adverse reactions requiring discontinuation
Documentation to bring
- Completed BCBSAZ prior authorization request form signed by prescribing provider
- Chart notes documenting diagnosis of moderate to severe OSA with obesity
- Lab results confirming Apnea Hypopnea Index (AHI) > 15 events/hour on polysomnogram
- Documentation of BMI >= 30 kg/m2 (or >= 95th percentile for pediatric patients)
- Paid claims or medical records confirming failure, contraindication, or intolerance to at least ONE non-GLP-1 weight loss medication (Contrave, orlistat, phentermine, or Qsymia) for at least 3 months
- Documentation confirming failure, contraindication, or intolerance to THREE generic equivalents for at least 3 months each
- Documentation confirming PAP therapy use or medical contraindication to PAP
- Documentation of participation in reduced calorie diet and physical activity program
- Documentation confirming no diagnosis of T1DM, T2DM, ketoacidosis, hyperosmolar state, or HbA1c > 6.5%
- Documentation confirming prescriber is a Pulmonologist or Sleep Medicine Physician, or that prescription is in consultation with one
- For continuation: chart notes with evidence of improvement in OSA (AHI improvement over baseline)
- For continuation: documentation of >= 5% reduction in body weight from baseline
- For continuation: lab values confirming safe use
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Both of the following required: (1) improvement in Apnea Hypopnea Index over baseline, and (2) reduction of 5% or more in body weight from baseline. Documented adherence to prescribed therapy regimen, continued reduced calorie diet (at least 500 kcal/day reduction) and physical activity (at least 150 min/week) also required. Diabetes exclusion (T1DM, T2DM, HbA1c >=6.5%) and PAP therapy requirement are re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Type 2 diabetes mellitus
- History of ketoacidosis
- Hyperosmolar state/coma
- HbA1c > 6.5%
- Concomitant use with GLP-1 agonists (e.g., Ozempic, Rybelsus, Trulicity, Mounjaro)
- Personal or family history of medullary thyroid carcinoma
- Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
- Prior serious hypersensitivity reaction (anaphylaxis, angioedema) to GLP-1 receptor agonists
- Severe gastrointestinal disease including severe gastroparesis
- Suicidal behavior or ideation
- Signs and symptoms of pancreatitis
- Gallbladder disease (cholelithiasis, cholecystitis)
- Use solely for weight loss (must also be treating OSA)
- Does not apply to Federal Employee Program, Medicare Advantage, Medicaid, or out-of-state BCBS plan members
- Pregnancy
- Type 1 diabetes
Policy note: PAP therapy is required unless medically contraindicated. Accepted PAP contraindications include: skin reactions or irritation, nasal polyposis/congestion/dryness unresponsive to nasal therapies, eye irritation from pressurized air, aerophagia, air leakage around device, psychosocial issues (claustrophobia, psychiatric disorders), and other physical limitations (arthritis, muscle weakness). The brand-specific criterion requires failure/contraindication/intolerance to THREE generic equivalents (if available) for at least 3 months each; FDA MedWatch reporting is expected for generic failures. Initial approval duration is 6 months or end of plan year; continuation approval is 12 months or end of plan year. Manufacturer assistance (coupons, samples) is NOT considered for continuation of therapy. For weight loss indication, the document explicitly directs to the member's benefit plan book rather than this PCG. OSA severity is defined by AHI > 15 events/hour (moderate to severe). The policy document is specific to Commercial and/or Marketplace plans only. Original effective date: 02/20/2025; Last criteria revision date: 08/21/2025.
Policy effective February 20, 2025 · verified June 2, 2026 · source: Download