Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Moderate to severe OSA with obesity
All of:
- Age ≥ 18 years
- Obesity (BMI ≥ 30 kg/m2)
- Diagnosis of moderate to severe OSA (AHI/REI ≥ 15 events/hour, or RDI reflecting moderate-severe disease)
Plus any one of:
- OSA diagnosis confirmed by attended polysomnography (PSG) with AHI ≥ 15
- OSA diagnosis confirmed by home sleep apnea testing (HSAT) with REI ≥ 15 (if PSG not indicated or available)
- RDI-based diagnosis reflecting clinically significant arousal-predominant obstructive events
Documentation to bring
- Diagnosis of moderate to severe OSA (AHI or REI ≥ 15 events/hour, or equivalent RDI)
- OSA diagnostic test result: polysomnography (PSG) preferred, or home sleep apnea test (HSAT) with technically adequate device
- BMI documentation ≥ 30 kg/m2 (obesity)
- If HSAT result is negative, inconclusive, or technically inadequate: PSG results required
- Documentation confirming OSA is not predominantly central or mixed (< 50% central or mixed apneas/hypopneas)
Not covered when
- Craniofacial abnormalities affecting respiration
- 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 or with any GLP-1 receptor agonist is not recommended
Policy note: FDA-approved for moderate to severe OSA in adults with obesity. The SURMOUNT-OSA program (two phase 3 trials) enrolled participants with mean AHIs of ~50 events/hour and mean BMIs ~39 kg/m2. Trial 1 enrolled participants NOT receiving PAP therapy; Trial 2 enrolled participants already on PAP therapy — indicating PAP trial is NOT required for eligibility. OSA severity grading uses AHI (PSG-derived, preferred), REI (HSAT-based surrogate), or RDI (broader physiologic assessment). The 'moderate to severe' OSA threshold per AASM standards is AHI/REI ≥ 15 events/hour; the document does not explicitly state a numeric threshold in the criteria section but the FDA indication and SURMOUNT-OSA trial context supports ≥ 15 as the qualifying threshold. Hypopnea scoring per AASM recommended rule: ≥ 30% airflow reduction ≥ 10 seconds with ≥ 3% O2 desaturation and/or arousal.
Policy effective May 18, 2026 · verified June 5, 2026 · source: Capital BlueCross Employer / Commercial Insurance prior authorization policy · View policy document (PDF)