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Highmark · Osa

Highmark coverage for Zepbound (Osa)

Employer / Commercial Insurance

Depends on your plan's benefit

Section VI applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit only. For members WITH the anti-obesity benefit, Zepbound for OSA may be covered under that benefit (criteria not fully specified in this section for those members). The document frames Section VI as the pathway for DE members without obesity benefit.

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • Diagnosis documented with a code (G47.33)
  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy

Qualification pathways

You can qualify through any one of these.

OSA Initiation (Section VI) - PAP-compliant pathway

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member is currently receiving and compliant with PAP, documented by device report showing device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA Initiation (Section VI) - PAP-intolerant pathway with oral appliance

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member has experienced therapeutic failure, intolerance, or contraindication to PAP
  • Member is using a custom, titratable oral appliance
  • Oral appliance prescribed by or in consultation with a sleep specialist
  • Prescriber documents that member has been adherent to the oral appliance
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA — T2DM step therapy (if applicable)

All of:

  • If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes (e.g., Ozempic, Mounjaro)

OSA Maintenance (Section VI)

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Member had a diagnosis of moderate to severe OSAHS (ICD-10: G47.33) prior to initiation of requested therapy
  • Baseline polysomnography demonstrating AHI or RDI >= 15 events per hour (sleep study)
  • Baseline AHI or RDI with use of PAP or oral appliance documented by sleep study or device report
  • Baseline BMI >= 30 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Table A documentation of continued dietary changes and physical activity
  • Chart note documentation that member is practicing sleep hygiene modifications in combination with therapy
  • Requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, OR prescriber attests titrating to 10 mg once weekly
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • >= 7 months of previous therapy

Plus any one of:

  • Decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation of Zepbound) as documented by PAP device report or sleep study
  • If baseline AHI/RDI with PAP or oral appliance use prior to Zepbound initiation was 0, then AHI/RDI remained at 0 as documented by PAP device report or sleep study

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 30 kg/m2)
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Documentation of baseline AHI or RDI WITH use of PAP or oral appliance (device report or sleep study)
  • Prescription by or consultation with a sleep specialist
  • For PAP-compliant pathway: PAP device report demonstrating device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • For PAP-intolerant pathway: documentation of PAP therapeutic failure, intolerance, or contraindication; documentation of current use of custom titratable oral appliance prescribed by sleep specialist; documentation of oral appliance adherence
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Chart notes documenting sleep hygiene modifications (sleep positioning to avoid supine, avoidance of alcohol and sedatives before bed) practiced for at least 6 months prior to initiation
  • If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA approved for diabetes (e.g., Ozempic, Mounjaro)
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: documentation of >= 25% decrease from baseline AHI/RDI (with prior PAP/OA use) OR documentation that AHI/RDI remained at 0 (if baseline was 0), via PAP device report or sleep study
  • For maintenance: documentation that member requires continued Zepbound to maintain the AHI/RDI reduction
  • For maintenance: documentation or attestation that requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, or titrating to 10 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for For OSA maintenance: member must demonstrate a decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation) as documented by PAP device report or sleep study; OR if baseline AHI/RDI with PAP/OA was 0, the AHI/RDI remains at 0. Member must require additional therapy with Zepbound to maintain the AHI/RDI decrease. Maintenance dose: 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 10 mg once weekly. T2DM step therapy requirement (failure of preferred diabetes GLP-1 RA) is re-verified at continuation. Ongoing PAP/OA use compliance and sleep specialist oversight continue to be required and staying on a maintenance dose of at least 10 mg.

Not covered when

  • AHI or RDI < 15 events per hour at baseline (Zepbound has not been studied at lower AHI)
  • BMI < 30 kg/m2 at baseline (Zepbound has not been studied below this threshold for OSA)
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • If T2DM (E11.9): must have failed preferred diabetes GLP-1 RA (e.g., Ozempic, Mounjaro) before Zepbound approved for OSA
  • Zepbound single-dose vials are only available for self-pay patients; vials cannot be billed through insurance
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Section VI (OSA indication) explicitly applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit. Members with the obesity benefit may also access Zepbound for OSA but the applicable criteria section for those members is less explicitly stated.

Policy note: Zepbound for OSA requires a sleep specialist (prescription by or consultation with). PAP compliance is required as a prerequisite OR documented failure/intolerance/contraindication to PAP with current compliant use of a custom titratable oral appliance. The AHI/RDI threshold of >= 15 corresponds to moderate-to-severe OSA. For continuation, a >= 25% reduction in AHI/RDI from the baseline-with-PAP/OA value must be demonstrated. The maintenance dose minimum for OSA is 10 mg once weekly (higher than the 5 mg minimum for weight loss). If T2DM, must first fail a preferred diabetes GLP-1 RA. Sleep hygiene modifications are required both prior to initiation and ongoing. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

ACA Marketplace

Depends on your plan's benefit

Section VI applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit only. For members WITH the anti-obesity benefit, Zepbound for OSA may be covered under that benefit (criteria not fully specified in this section for those members). The document frames Section VI as the pathway for DE members without obesity benefit.

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • Diagnosis documented with a code (G47.33)
  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy

Qualification pathways

You can qualify through any one of these.

OSA Initiation (Section VI) - PAP-compliant pathway

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member is currently receiving and compliant with PAP, documented by device report showing device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA Initiation (Section VI) - PAP-intolerant pathway with oral appliance

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (OSAHS) (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Baseline AHI or RDI with use of PAP or oral appliance documented by device report or sleep study
  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication with BMI >= 30 kg/m2
  • Member has experienced therapeutic failure, intolerance, or contraindication to PAP
  • Member is using a custom, titratable oral appliance
  • Oral appliance prescribed by or in consultation with a sleep specialist
  • Prescriber documents that member has been adherent to the oral appliance
  • Table A documentation of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Chart note documentation of sleep hygiene modifications practiced for at least 6 months prior to initiation AND will continue during therapy
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • 0 to < 7 months of previous therapy

OSA — T2DM step therapy (if applicable)

All of:

  • If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes (e.g., Ozempic, Mounjaro)

OSA Maintenance (Section VI)

All of:

  • Member is 18 years of age or older
  • Medication prescribed by or in consultation with a sleep specialist
  • Member had a diagnosis of moderate to severe OSAHS (ICD-10: G47.33) prior to initiation of requested therapy
  • Baseline polysomnography demonstrating AHI or RDI >= 15 events per hour (sleep study)
  • Baseline AHI or RDI with use of PAP or oral appliance documented by sleep study or device report
  • Baseline BMI >= 30 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Table A documentation of continued dietary changes and physical activity
  • Chart note documentation that member is practicing sleep hygiene modifications in combination with therapy
  • Requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, OR prescriber attests titrating to 10 mg once weekly
  • Member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • >= 7 months of previous therapy

Plus any one of:

  • Decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation of Zepbound) as documented by PAP device report or sleep study
  • If baseline AHI/RDI with PAP or oral appliance use prior to Zepbound initiation was 0, then AHI/RDI remained at 0 as documented by PAP device report or sleep study

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 30 kg/m2)
  • Diagnosis of moderate to severe obstructive sleep apnea/hypopnea syndrome (ICD-10: G47.33)
  • Baseline polysomnography or recording time (without PAP or oral appliance during testing) demonstrating AHI or RDI >= 15 events per hour
  • Documentation of baseline AHI or RDI WITH use of PAP or oral appliance (device report or sleep study)
  • Prescription by or consultation with a sleep specialist
  • For PAP-compliant pathway: PAP device report demonstrating device used for >= 70% of nights for >= 4 hours per night for >= 2 months
  • For PAP-intolerant pathway: documentation of PAP therapeutic failure, intolerance, or contraindication; documentation of current use of custom titratable oral appliance prescribed by sleep specialist; documentation of oral appliance adherence
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Chart notes documenting sleep hygiene modifications (sleep positioning to avoid supine, avoidance of alcohol and sedatives before bed) practiced for at least 6 months prior to initiation
  • If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA approved for diabetes (e.g., Ozempic, Mounjaro)
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: documentation of >= 25% decrease from baseline AHI/RDI (with prior PAP/OA use) OR documentation that AHI/RDI remained at 0 (if baseline was 0), via PAP device report or sleep study
  • For maintenance: documentation that member requires continued Zepbound to maintain the AHI/RDI reduction
  • For maintenance: documentation or attestation that requested dose is 10 mg, 12.5 mg, or 15 mg once weekly, or titrating to 10 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for For OSA maintenance: member must demonstrate a decrease of >= 25% from baseline AHI/RDI (with PAP or oral appliance use prior to initiation) as documented by PAP device report or sleep study; OR if baseline AHI/RDI with PAP/OA was 0, the AHI/RDI remains at 0. Member must require additional therapy with Zepbound to maintain the AHI/RDI decrease. Maintenance dose: 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 10 mg once weekly. T2DM step therapy requirement (failure of preferred diabetes GLP-1 RA) is re-verified at continuation. Ongoing PAP/OA use compliance and sleep specialist oversight continue to be required and staying on a maintenance dose of at least 10 mg.

Not covered when

  • AHI or RDI < 15 events per hour at baseline (Zepbound has not been studied at lower AHI)
  • BMI < 30 kg/m2 at baseline (Zepbound has not been studied below this threshold for OSA)
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • If T2DM (E11.9): must have failed preferred diabetes GLP-1 RA (e.g., Ozempic, Mounjaro) before Zepbound approved for OSA
  • Zepbound single-dose vials are only available for self-pay patients; vials cannot be billed through insurance
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Section VI (OSA indication) explicitly applies to members with a Delaware Commercial fully-insured or Healthcare Reform plan WITHOUT the obesity benefit. Members with the obesity benefit may also access Zepbound for OSA but the applicable criteria section for those members is less explicitly stated.

Policy note: Zepbound for OSA requires a sleep specialist (prescription by or consultation with). PAP compliance is required as a prerequisite OR documented failure/intolerance/contraindication to PAP with current compliant use of a custom titratable oral appliance. The AHI/RDI threshold of >= 15 corresponds to moderate-to-severe OSA. For continuation, a >= 25% reduction in AHI/RDI from the baseline-with-PAP/OA value must be demonstrated. The maintenance dose minimum for OSA is 10 mg once weekly (higher than the 5 mg minimum for weight loss). If T2DM, must first fail a preferred diabetes GLP-1 RA. Sleep hygiene modifications are required both prior to initiation and ongoing. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

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