Applies to Employer plans.
Depends on your plan's benefitPatient must have anti-obesity medication coverage benefits (criterion 7 of initial criteria; criterion 4 of continuation criteria)
Qualification pathways
You can qualify through any one of these.
OSA in adults with obesity
All of:
- Patient is 18 years of age or older
- Diagnosis of moderate to severe obstructive sleep apnea
- BMI ≥ 30 kg/m2
- Polysomnography (PSG) or home sleep apnea test performed
- Apnea hypopnea index (AHI) ≥ 15 at baseline
- Requested medication will NOT be used concurrently with another GLP-1 receptor agonist
- Requested medication will NOT be used concurrently with another weight loss medication
- Provider has addressed requirement for lifestyle modifications
- Patient has anti-obesity medication coverage benefits
Plus any one of:
- Patient was unable to achieve acceptable weight loss (1 lb/week) through lifestyle modifications over 6 months
- Patient has a weight-related comorbidity (e.g., OSA) that warrants immediate medication intervention
Documentation to bring
- Documentation of moderate to severe obstructive sleep apnea diagnosis
- Baseline BMI ≥ 30 kg/m2
- Polysomnography (PSG) or home sleep apnea test results showing AHI ≥ 15 at baseline
- Documentation that provider addressed lifestyle modification requirement
- Documentation of 6-month lifestyle modification attempt with failure to achieve 1 lb/week weight loss, OR documentation of OSA as weight-related comorbidity warranting immediate medication intervention
- Documentation that patient is not concurrently using another GLP-1 receptor agonist
- Documentation that patient is not concurrently using another weight loss medication
- Confirmation of anti-obesity medication coverage benefits
Quantity limits
- 2.5 mg/0.5 mL — 4 pens per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: Patient with OSA must demonstrate a positive clinical response while using the medication. No weight loss percentage threshold required for continuation of OSA indication.
Not covered when
- Concurrent use of another GLP-1 receptor agonist
- Concurrent use of another weight loss medication
Policy note: OSA indication for Zepbound added January 2025, criteria updated April 2025. Policy requires AHI ≥ 15 (moderate OSA threshold) confirmed by PSG or home sleep apnea test. No PAP therapy trial requirement stated. The OSA pathway requires BMI ≥ 30 (not BMI ≥ 27 with comorbidity). Continuation for OSA requires positive clinical response rather than a specific weight loss percentage. The lifestyle modification criteria (items 3-6) from the broader initial criteria section apply to all drugs in the Foundayo/Saxenda/Wegovy/Zepbound group including OSA indication.
Policy effective July 1, 2026 · verified July 16, 2026 · source: BCBS North Carolina Employer / Commercial Insurance prior authorization policy · View policy document (PDF)