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BCBS Rhode Island · Osa

BCBS Rhode Island coverage for Zepbound (Osa)

Employer / Commercial Insurance

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.

Moderate to severe OSA with obesity

All of:

  • Adult (age >= 18 years)
  • BMI >= 30 kg/m2 (obesity)
  • Diagnosis of moderate to severe OSA (AHI >= 15 events/hour or REI/RDI equivalent per PSG or HSAT)

Plus any one of:

  • Patient not currently receiving PAP therapy
  • Patient currently receiving PAP therapy (both populations studied in SURMOUNT-OSA)

Documentation to bring

  • Diagnosis of moderate to severe OSA confirmed by polysomnography (PSG) or home sleep apnea testing (HSAT)
  • AHI, REI, or RDI result documenting moderate to severe OSA (AHI >= 15 events/hour)
  • Baseline BMI >= 30 kg/m2 (obesity)
  • Age >= 18 years

Not covered when

  • Craniofacial abnormalities affecting respiration (per SURMOUNT-OSA exclusion criteria)
  • Predominantly central or mixed sleep apnea (>= 50% central or mixed apneas/hypopneas)
  • Cheyne-Stokes respiration
  • Obesity hypoventilation syndrome
  • Evidence of daytime hypercapnia
  • Coadministration with other tirzepatide-containing products not recommended
  • Coadministration with any GLP-1 receptor agonist not recommended

Policy note: FDA indication is for moderate to severe OSA in adults with obesity. The SURMOUNT-OSA program (two Phase 3 trials) enrolled participants with mean AHI ~50 events/hour and mean BMI ~39 kg/m2. Trial 1 enrolled patients not on PAP therapy; Trial 2 enrolled patients on PAP therapy. The document notes AHI from PSG is the preferred diagnostic index; REI (HSAT-based) is acceptable surrogate but may underestimate severity; RDI may identify arousal-based disease. PAP therapy trial is NOT required as a prerequisite per the clinical rationale. OSA AHI minimum set to 15 events/hour based on the definition of moderate OSA (the FDA indication requires 'moderate to severe'). AASM recommended hypopnea scoring: >= 3% oxygen desaturation and/or arousal.

Policy effective May 4, 2026 · verified June 2, 2026 · source: RI_Weight_Management_ProgSum.pdf

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.

Moderate to severe OSA with obesity

All of:

  • Adult (age >= 18 years)
  • BMI >= 30 kg/m2 (obesity)
  • Diagnosis of moderate to severe OSA (AHI >= 15 events/hour or REI/RDI equivalent per PSG or HSAT)

Plus any one of:

  • Patient not currently receiving PAP therapy
  • Patient currently receiving PAP therapy (both populations studied in SURMOUNT-OSA)

Documentation to bring

  • Diagnosis of moderate to severe OSA confirmed by polysomnography (PSG) or home sleep apnea testing (HSAT)
  • AHI, REI, or RDI result documenting moderate to severe OSA (AHI >= 15 events/hour)
  • Baseline BMI >= 30 kg/m2 (obesity)
  • Age >= 18 years

Not covered when

  • Craniofacial abnormalities affecting respiration (per SURMOUNT-OSA exclusion criteria)
  • Predominantly central or mixed sleep apnea (>= 50% central or mixed apneas/hypopneas)
  • Cheyne-Stokes respiration
  • Obesity hypoventilation syndrome
  • Evidence of daytime hypercapnia
  • Coadministration with other tirzepatide-containing products not recommended
  • Coadministration with any GLP-1 receptor agonist not recommended

Policy note: FDA indication is for moderate to severe OSA in adults with obesity. The SURMOUNT-OSA program (two Phase 3 trials) enrolled participants with mean AHI ~50 events/hour and mean BMI ~39 kg/m2. Trial 1 enrolled patients not on PAP therapy; Trial 2 enrolled patients on PAP therapy. The document notes AHI from PSG is the preferred diagnostic index; REI (HSAT-based) is acceptable surrogate but may underestimate severity; RDI may identify arousal-based disease. PAP therapy trial is NOT required as a prerequisite per the clinical rationale. OSA AHI minimum set to 15 events/hour based on the definition of moderate OSA (the FDA indication requires 'moderate to severe'). AASM recommended hypopnea scoring: >= 3% oxygen desaturation and/or arousal.

Policy effective May 4, 2026 · verified June 2, 2026 · source: RI_Weight_Management_ProgSum.pdf

All Zepbound policies under BCBS Rhode Island · Check your card