Diagnosis of moderate to severe obstructive sleep apnea
Obesity (BMI >= 30 kg/m2)
Age >= 18 years old
Current baseline weight documented
Physician attestation that member will participate in lifestyle modifications to promote weight loss (healthy eating, exercise if appropriate)
Not to be used in combination with other weight loss products
Cannot be used in combination with other GLP-1 agonist containing products
Documentation to bring
Diagnosis of moderate to severe obstructive sleep apnea
BMI documentation >= 30 kg/m2
Current baseline weight
Physician attestation that member will participate in lifestyle modifications to promote weight loss
For continuation: Current weight (within 30 days)
For continuation: Physician attestation of >= 5% weight loss from baseline and continued active participation in lifestyle modifications
Approval and renewal
Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Physician attestation that member maintains at least 5% weight loss from baseline; current weight must be submitted to plan; attestation of continued active participation in lifestyle modifications supporting weight loss. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
Cannot be used in combination with other weight loss products
Cannot be used in combination with other GLP-1 agonist containing products
Policy note: The OSA indication is listed under the Pathway 1 group benefit section as an alternative qualifying criterion. The document states 'Treatment of moderate to severe obstructive sleep apnea in adults with obesity (BMI 30 kg/m2 or greater)'. No minimum AHI threshold is specified, and no PAP/CPAP trial requirement is stated. The same continuation criteria as the weight_loss Pathway 1 apply (5% weight loss from baseline). Coverage is subject to group benefit determination.
Policy effective June 1, 2026 · verified June 2, 2026 · source: prior-authorization-and-step-therapy-guidelines.pdf
ACA Marketplace
Covered with requirements
What you need to qualify
Age 18 and older
BMI of 30 or higher
Diagnosed obstructive sleep apnea
Qualification pathways
You can qualify through any one of these.
OSA with Obesity
All of:
Diagnosis of moderate to severe obstructive sleep apnea
Obesity (BMI >= 30 kg/m2)
Age >= 18 years old
Current baseline weight documented
Physician attestation that member will participate in lifestyle modifications to promote weight loss (healthy eating, exercise if appropriate)
Not to be used in combination with other weight loss products
Cannot be used in combination with other GLP-1 agonist containing products
Documentation to bring
Diagnosis of moderate to severe obstructive sleep apnea
BMI documentation >= 30 kg/m2
Current baseline weight
Physician attestation that member will participate in lifestyle modifications to promote weight loss
For continuation: Current weight (within 30 days)
For continuation: Physician attestation of >= 5% weight loss from baseline and continued active participation in lifestyle modifications
Approval and renewal
Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Physician attestation that member maintains at least 5% weight loss from baseline; current weight must be submitted to plan; attestation of continued active participation in lifestyle modifications supporting weight loss. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
Cannot be used in combination with other weight loss products
Cannot be used in combination with other GLP-1 agonist containing products
Policy note: The OSA indication is listed under the Pathway 1 group benefit section as an alternative qualifying criterion. The document states 'Treatment of moderate to severe obstructive sleep apnea in adults with obesity (BMI 30 kg/m2 or greater)'. No minimum AHI threshold is specified, and no PAP/CPAP trial requirement is stated. The same continuation criteria as the weight_loss Pathway 1 apply (5% weight loss from baseline). Coverage is subject to group benefit determination.
Policy effective June 1, 2026 · verified June 2, 2026 · source: prior-authorization-and-step-therapy-guidelines.pdf
