Employer / Commercial Insurance
Covered with requirements
What you need to qualify
- Age 18 and older
- BMI of 35 or higher
- 3 months of a documented diet and exercise program
- Prior trial of another GLP-1 medication (Wegovy (semaglutide for overweight or obesity) and liraglutide for overweight or obesity) for at least 90 days
- Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
OSA — BMI >=50 (no prior GLP-1 step therapy required at this BMI tier)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=50 kg/m2
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
OSA — BMI 35 to <50 (requires prior GLP-1 step therapy)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=35 to <50 kg/m2
- Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight or obesity, followed by semaglutide for overweight or obesity)
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
Documentation to bring
- Moderate-to-severe OSA diagnosis confirmed by polysomnography within past year (AHI 15-29 for moderate, AHI >=30 for severe)
- Documentation of PAP therapy status: either inability to use PAP (documented anxiety, nasal/oral discomfort) OR documentation of PAP use for at least 3 months with plan to continue
- Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is a Pulmonologist or Weight Management Specialist
- Patient age documentation (>=18 years)
- Documented baseline weight within past 30 days
- Documented baseline BMI
- Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
- For BMI 35 to <50: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight/obesity followed by semaglutide for overweight/obesity)
- Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Confirmation of absence of all reasons for non-coverage (T1/T2DM, central/mixed sleep apnea, prior/planned surgical treatment for OSA or obesity, significant renal/pulmonary/liver disease, other relevant comorbidities/medications, pancreatitis history, MTC/MEN2 history)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for 25% improvement in AHI from baseline. Must continue actively adhering to prescriber-documented lifestyle interventions (with nutrition and physical activity components). BMI >=27 kg/m2 required. No reasons for non-coverage. Baseline BMI is explicitly NOT re-evaluated at continuation — policy states 'do not consider baseline BMI over the course of treatment; baseline BMI was considered when this therapy course was initially approved.'.
Not covered when
- Type 2 diabetes
- Central or mixed sleep apnea
- Prior or planned surgical or minimally invasive treatment for OSA or obesity
- Significant renal, pulmonary, or liver disease
- Other comorbidities or medications that may affect weight or daytime sleepiness
- Prior acute or chronic pancreatitis
- Personal or family history of MTC or MEN2
- Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Type 1 diabetes
Policy note: OSA indication applies to Zepbound ONLY. Polysomnography must be within the past year. Moderate OSA: AHI 15-29; severe OSA: AHI >=30. PAP therapy requirement: patient must either be unable to use PAP OR have used PAP for at least 3 months (and plan to continue). For BMI >=50: no prior GLP-1 step therapy required. For BMI 35 to <50: requires prior failure of Wegovy (or liraglutide for obesity followed by semaglutide for obesity) — 3-month trial at maximum tolerated dose. Note: policy states that if liraglutide or semaglutide are prescribed for OSA indication, Zepbound's OSA criteria will be applied. Continuation: baseline BMI explicitly not re-evaluated; continuation based on 25% AHI improvement, lifestyle adherence, BMI >=27, and no reasons for non-coverage. Exclusions are based on SURMOUNT-OSA trial exclusion criteria.
Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf
ACA Marketplace
Covered with requirements
What you need to qualify
- Age 18 and older
- BMI of 35 or higher
- 3 months of a documented diet and exercise program
- Prior trial of another GLP-1 medication (Wegovy (semaglutide for overweight or obesity) and liraglutide for overweight or obesity) for at least 90 days
- Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
OSA — BMI >=50 (no prior GLP-1 step therapy required at this BMI tier)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=50 kg/m2
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
OSA — BMI 35 to <50 (requires prior GLP-1 step therapy)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=35 to <50 kg/m2
- Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight or obesity, followed by semaglutide for overweight or obesity)
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
Documentation to bring
- Moderate-to-severe OSA diagnosis confirmed by polysomnography within past year (AHI 15-29 for moderate, AHI >=30 for severe)
- Documentation of PAP therapy status: either inability to use PAP (documented anxiety, nasal/oral discomfort) OR documentation of PAP use for at least 3 months with plan to continue
- Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is a Pulmonologist or Weight Management Specialist
- Patient age documentation (>=18 years)
- Documented baseline weight within past 30 days
- Documented baseline BMI
- Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
- For BMI 35 to <50: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight/obesity followed by semaglutide for overweight/obesity)
- Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Confirmation of absence of all reasons for non-coverage (T1/T2DM, central/mixed sleep apnea, prior/planned surgical treatment for OSA or obesity, significant renal/pulmonary/liver disease, other relevant comorbidities/medications, pancreatitis history, MTC/MEN2 history)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for 25% improvement in AHI from baseline. Must continue actively adhering to prescriber-documented lifestyle interventions (with nutrition and physical activity components). BMI >=27 kg/m2 required. No reasons for non-coverage. Baseline BMI is explicitly NOT re-evaluated at continuation — policy states 'do not consider baseline BMI over the course of treatment; baseline BMI was considered when this therapy course was initially approved.'.
Not covered when
- Type 2 diabetes
- Central or mixed sleep apnea
- Prior or planned surgical or minimally invasive treatment for OSA or obesity
- Significant renal, pulmonary, or liver disease
- Other comorbidities or medications that may affect weight or daytime sleepiness
- Prior acute or chronic pancreatitis
- Personal or family history of MTC or MEN2
- Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Type 1 diabetes
Policy note: OSA indication applies to Zepbound ONLY. Polysomnography must be within the past year. Moderate OSA: AHI 15-29; severe OSA: AHI >=30. PAP therapy requirement: patient must either be unable to use PAP OR have used PAP for at least 3 months (and plan to continue). For BMI >=50: no prior GLP-1 step therapy required. For BMI 35 to <50: requires prior failure of Wegovy (or liraglutide for obesity followed by semaglutide for obesity) — 3-month trial at maximum tolerated dose. Note: policy states that if liraglutide or semaglutide are prescribed for OSA indication, Zepbound's OSA criteria will be applied. Continuation: baseline BMI explicitly not re-evaluated; continuation based on 25% AHI improvement, lifestyle adherence, BMI >=27, and no reasons for non-coverage. Exclusions are based on SURMOUNT-OSA trial exclusion criteria.
Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf
Federal Employee Program
Covered with requirements
What you need to qualify
- Age 18 and older
- BMI of 35 or higher
- 3 months of a documented diet and exercise program
- Prior trial of another GLP-1 medication (Wegovy (semaglutide for overweight or obesity) and liraglutide for overweight or obesity) for at least 90 days
- Diagnosed obstructive sleep apnea (AHI of 15 or higher), with a documented trial of PAP therapy
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
OSA — BMI >=50 (no prior GLP-1 step therapy required at this BMI tier)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=50 kg/m2
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
OSA — BMI 35 to <50 (requires prior GLP-1 step therapy)
All of:
- Moderate-to-severe OSA diagnosis: moderate OSA by polysomnography within past year with AHI 15-29, OR severe OSA with AHI >=30
- PAP therapy: unable to use PAP therapy (documented anxiety with use, documented nasal/oral discomfort preventing adequate sleep, etc.) OR if able to use PAP, must have used for at least 3 months and plan to continue
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Pulmonologist or Weight Management Specialist
- Age >= 18 years
- Documented baseline weight within past 30 days
- Actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components) and will continue
- Baseline BMI >=35 to <50 kg/m2
- Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight or obesity, followed by semaglutide for overweight or obesity)
- Not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- No reasons for non-coverage (T1D or T2D; central or mixed sleep apnea; prior or planned surgical/minimally invasive treatment for OSA or obesity; significant renal/pulmonary/liver disease; other comorbidities or medications affecting weight or daytime sleepiness; prior acute or chronic pancreatitis; personal or family history of MTC or MEN2)
Documentation to bring
- Moderate-to-severe OSA diagnosis confirmed by polysomnography within past year (AHI 15-29 for moderate, AHI >=30 for severe)
- Documentation of PAP therapy status: either inability to use PAP (documented anxiety, nasal/oral discomfort) OR documentation of PAP use for at least 3 months with plan to continue
- Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is a Pulmonologist or Weight Management Specialist
- Patient age documentation (>=18 years)
- Documented baseline weight within past 30 days
- Documented baseline BMI
- Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
- For BMI 35 to <50: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of Wegovy (or liraglutide for overweight/obesity followed by semaglutide for overweight/obesity)
- Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Confirmation of absence of all reasons for non-coverage (T1/T2DM, central/mixed sleep apnea, prior/planned surgical treatment for OSA or obesity, significant renal/pulmonary/liver disease, other relevant comorbidities/medications, pancreatitis history, MTC/MEN2 history)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for 25% improvement in AHI from baseline. Must continue actively adhering to prescriber-documented lifestyle interventions (with nutrition and physical activity components). BMI >=27 kg/m2 required. No reasons for non-coverage. Baseline BMI is explicitly NOT re-evaluated at continuation — policy states 'do not consider baseline BMI over the course of treatment; baseline BMI was considered when this therapy course was initially approved.'.
Not covered when
- Type 2 diabetes
- Central or mixed sleep apnea
- Prior or planned surgical or minimally invasive treatment for OSA or obesity
- Significant renal, pulmonary, or liver disease
- Other comorbidities or medications that may affect weight or daytime sleepiness
- Prior acute or chronic pancreatitis
- Personal or family history of MTC or MEN2
- Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
- Type 1 diabetes
Policy note: OSA indication applies to Zepbound ONLY. Polysomnography must be within the past year. Moderate OSA: AHI 15-29; severe OSA: AHI >=30. PAP therapy requirement: patient must either be unable to use PAP OR have used PAP for at least 3 months (and plan to continue). For BMI >=50: no prior GLP-1 step therapy required. For BMI 35 to <50: requires prior failure of Wegovy (or liraglutide for obesity followed by semaglutide for obesity) — 3-month trial at maximum tolerated dose. Note: policy states that if liraglutide or semaglutide are prescribed for OSA indication, Zepbound's OSA criteria will be applied. Continuation: baseline BMI explicitly not re-evaluated; continuation based on 25% AHI improvement, lifestyle adherence, BMI >=27, and no reasons for non-coverage. Exclusions are based on SURMOUNT-OSA trial exclusion criteria.
Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf
