Diagnosed obstructive sleep apnea (AHI of 15 or higher)
Qualification 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
To renew, the plan looks for 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.html
ACA Marketplace
Covered with requirements
What you need to qualify
Age 18 and older
BMI of 30 or higher
Diagnosed obstructive sleep apnea (AHI of 15 or higher)
Qualification 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
To renew, the plan looks for 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.html
