Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial approval - OSA
All of:
- OSA diagnosis confirmed by polysomnography (PSG) or home sleep apnea test
- AHI ≥ 15 events/hour from baseline (prior to initiation of pharmacotherapy)
- Requested agent is Zepbound
- BMI ≥ 30 kg/m2
- Patient does not have craniofacial abnormalities that may affect breathing
- Patient does NOT have diagnosis of central or mixed sleep apnea with mixed or central apneas/hypopneas ≥ 50%
- Patient does NOT have diagnosis of Cheyne Stokes Respiration
- Patient does NOT have diagnosis of Obesity Hypoventilation Syndrome or daytime hypercapnia
- Patient is not pregnant
- Requested agent will NOT be used in combination with another GLP-1 receptor agonist
- Requested agent will NOT be used in combination with another weight loss agent
Documentation to bring
- Polysomnography (PSG) or home sleep apnea test results confirming OSA diagnosis
- Documentation of AHI ≥ 15 events/hour at baseline
- Documentation of BMI ≥ 30 kg/m2
- Documentation that patient does not have craniofacial abnormalities affecting breathing
- Documentation that patient does not have central/mixed sleep apnea (≥ 50% central/mixed apneas/hypopneas)
- Documentation that patient does not have Cheyne Stokes Respiration
- Documentation that patient does not have Obesity Hypoventilation Syndrome or daytime hypercapnia
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient must demonstrate clinical benefit with requested agent (e.g., reduction in AHI, decrease in Epworth Sleepiness Scale). Patient must not be pregnant and not currently treated with another GLP-1 receptor agonist.
Not covered when
- Craniofacial abnormalities that may affect breathing
- Central or mixed sleep apnea with mixed or central apneas/hypopneas ≥ 50%
- Cheyne Stokes Respiration
- Obesity Hypoventilation Syndrome or daytime hypercapnia
- Combination with another GLP-1 receptor agonist not permitted
- Combination with another weight loss agent not permitted
- Pregnancy
Policy note: OSA criteria added 06-30-2025. Only Zepbound is eligible for the OSA indication per policy. No PAP/CPAP prior trial required. Renewal requires clinical benefit evidence (e.g., AHI reduction or improved Epworth Sleepiness Scale score).
Policy effective July 1, 2023 · verified June 2, 2026 · source: Policy 211