Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification 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
- Renewal: 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 Prog Sum · View policy document (PDF)