Cigna · Osa

Cigna 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.

Initial Approval - Moderate to Severe OSA with Obesity

All of:

Patient is >= 18 years of age
Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
Sleep study showing diagnosis of moderate to severe OSA
Sleep study showing apnea-hypopnea index (AHI) >= 15 events per hour
Patient does NOT have central sleep apnea
Patient does NOT have Cheyne Stokes respiration
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Continuation - Moderate to Severe OSA with Obesity

All of:

Patient is >= 18 years of age
Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
Patient has completed >= 1 year of therapy with Zepbound
Patient has lost >= 10% of baseline body weight
Prescriber attests patient has stability in OSA signs or symptoms
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Documentation to bring

Baseline BMI documentation (>= 30 kg/m2, prior to any GLP-1 or GLP-1/GIP agonist)
Sleep study results documenting moderate to severe OSA diagnosis
Sleep study results documenting AHI >= 15 events per hour
Confirmation patient does not have central sleep apnea or Cheyne Stokes respiration
Documentation of >= 10% baseline body weight loss (continuation)
Prescriber attestation of stability in OSA signs or symptoms (continuation)

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 10% weight loss from the starting weight and Continuation requires: >= 10% baseline body weight loss AND prescriber attestation of stability in OSA signs or symptoms (e.g., snoring, excessive daytime sleepiness, fatigue). Patient must have completed >= 1 year of initial therapy. PAP therapy status is NOT re-evaluated at continuation. OSA AHI is not re-measured at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Central sleep apnea is excluded
Cheyne Stokes respiration is excluded
Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists is not covered

Policy note: PAP/CPAP trial is NOT required prior to approval; patients using PAP therapy or not using PAP therapy are both eligible. Sleep study must document AHI >= 15 events/hour but there is no specific timeframe requirement for how recent the sleep study must be (a prior requirement for within 1 year was removed in May 2025). Moderate OSA = AHI >= 15; Severe OSA = AHI >= 30. Continuation requires >= 10% body weight loss (higher than the 5% threshold for weight loss indication). No pediatric indication for OSA.

Policy effective April 15, 2026 · verified June 2, 2026 · source: cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.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.

Initial Approval - Moderate to Severe OSA with Obesity

All of:

Patient is >= 18 years of age
Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
Sleep study showing diagnosis of moderate to severe OSA
Sleep study showing apnea-hypopnea index (AHI) >= 15 events per hour
Patient does NOT have central sleep apnea
Patient does NOT have Cheyne Stokes respiration
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Continuation - Moderate to Severe OSA with Obesity

All of:

Patient is >= 18 years of age
Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
Patient has completed >= 1 year of therapy with Zepbound
Patient has lost >= 10% of baseline body weight
Prescriber attests patient has stability in OSA signs or symptoms
Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Documentation to bring

Baseline BMI documentation (>= 30 kg/m2, prior to any GLP-1 or GLP-1/GIP agonist)
Sleep study results documenting moderate to severe OSA diagnosis
Sleep study results documenting AHI >= 15 events per hour
Confirmation patient does not have central sleep apnea or Cheyne Stokes respiration
Documentation of >= 10% baseline body weight loss (continuation)
Prescriber attestation of stability in OSA signs or symptoms (continuation)

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for at least 10% weight loss from the starting weight and Continuation requires: >= 10% baseline body weight loss AND prescriber attestation of stability in OSA signs or symptoms (e.g., snoring, excessive daytime sleepiness, fatigue). Patient must have completed >= 1 year of initial therapy. PAP therapy status is NOT re-evaluated at continuation. OSA AHI is not re-measured at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Central sleep apnea is excluded
Cheyne Stokes respiration is excluded
Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists is not covered

Policy effective April 15, 2026 · verified June 2, 2026 · source: cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf

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