BCBS Wyoming · Osa

BCBS Wyoming coverage for Zepbound (Osa)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

BMI of 30 or higher
Prescribed by or in consultation with a specialist
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

Qualification pathways

You can qualify through any one of these.

OSA - Initial Approval (Zepbound only)

All of:

Diagnosis of obstructive sleep apnea (OSA)
Polysomnography (PSG) or home sleep apnea test performed
AHI >= 15 events/hour from baseline (prior to initiation of pharmacotherapy)
Requested agent is Zepbound
BMI >= 30 kg/m^2
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
Prescriber is a specialist (e.g., pulmonologist, sleep specialist) or has consulted with a specialist

Documentation to bring

Medical records confirming diagnosis of obstructive sleep apnea (OSA)
Polysomnography (PSG) or home sleep apnea test results showing AHI >= 15 events/hour at baseline
Documentation of BMI >= 30 kg/m^2
Documentation that patient does NOT have craniofacial abnormalities affecting breathing
Documentation that patient does NOT have Central or Mixed Sleep Apnea with >= 50% mixed or central apneas/hypopneas
Documentation that patient does NOT have Cheyne Stokes Respiration
Documentation that patient does NOT have Obesity Hypoventilation Syndrome or daytime hypercapnia
Documentation of specialist prescriber or specialist consultation (e.g., pulmonologist, sleep specialist)

Quantity limits

2.5 MG/0.5 ML vial — 4 Vials per 180 days (84-day)
5 MG/0.5 ML vial, 7.5 MG/0.5 ML vial, 10 MG/0.5 ML vial, 12.5 MG/0.5 ML vial, 15 MG/0.5 ML vial — 4 Vials per 28 days
2.5 MG/0.5 ML autoinjector — 4 Pens per 180 days (84-day)
5 MG/0.5 ML autoinjector, 7.5 MG/0.5 ML autoinjector, 10 MG/0.5 ML autoinjector, 12.5 MG/0.5 ML autoinjector, 15 MG/0.5 ML autoinjector — 4 Pens per 28 days
2.5 MG/0.6 ML KwikPen — 1 Pen per 180 days (84-day)
5 MG/0.6 ML KwikPen, 7.5 MG/0.6 ML KwikPen, 10 MG/0.6 ML KwikPen, 12.5 MG/0.6 ML KwikPen, 15 MG/0.6 ML KwikPen — 1 Pen per 28 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Patient must demonstrate clinical benefit with the requested agent (e.g., reduction in AHI, decrease in Epworth Sleepiness Scale). AHI baseline measurement and PSG/home sleep test are NOT re-required at renewal. Specialist/consultation requirement remains.

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
Any FDA labeled contraindications to the requested agent

Policy note: Policy does NOT require prior PAP/CPAP therapy trial for OSA indication. AHI threshold is >= 15 events/hour (moderate-to-severe OSA). At renewal, clinical benefit is required (e.g., reduction in AHI, decrease in Epworth Sleepiness Scale) but repeat PSG/home sleep test is not explicitly required. Specialist (e.g., pulmonologist, sleep specialist) or specialist consultation required at both initial and renewal.

Policy effective June 1, 2026 · verified June 4, 2026 · source: WY_Weight_Management_PAQL_ProgSum.pdf

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