Premera 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.

OSA indication — moderate to severe OSA in adults with obesity

All of:

Age >= 18 years
BMI >= 30 kg/m2
Sleep study within the past 12 months showing AHI >= 15 events per hour
NOT diagnosed with central sleep apnea with >= 50% central apneas/hypopneas
NOT diagnosed with Cheyne Stokes respiration
Medication used as adjunct to reduced-calorie diet and increased physical activity
Dose limited to 15 mg once weekly
Quantity limited to 4 prefilled pens or single-dose vials per 28 days, OR 1 Kwikpen or multi-dose vial per 28 days
Not used concurrently with other weight loss medications

Documentation to bring

Office visit notes containing baseline body weight and BMI (>= 30 kg/m2)
Sleep study results within the past 12 months documenting AHI >= 15 events per hour
Documentation confirming absence of central sleep apnea (>= 50% central apneas/hypopneas) and absence of Cheyne Stokes respiration
Medication dosage documentation

Quantity limits

2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg — 4 prefilled pens or single-dose vials per 28 days, OR 1 Kwikpen or multi-dose vial per 28 days

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, >=10% baseline body weight loss after 12 months of treatment AND stability in OSA signs or symptoms such as snoring, excessive daytime sleepiness, and fatigue AND continued adherence to reduced-calorie diet and increased physical activity AND baseline BMI >= 30 kg/m2 AND age >= 18 years, and at least 52 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Central sleep apnea with >= 50% of central apneas/hypopneas
Cheyne Stokes respiration
Concurrent use with other weight loss medications (phentermine, phentermine/topiramate ER, benzphetamine, diethylpropion, phendimetrazine, Alli, Contrave, liraglutide 18 mg/3 mL pen, Qsymia, Saxenda, Xenical, Wegovy)
All uses other than FDA-approved dosage and administration are considered investigational
Coverage subject to benefit plan; many plans exclude weight management drugs
This medical policy does not apply to Medicare Advantage

Policy note: OSA indication requires moderate-to-severe OSA (AHI >= 15 events/hour) confirmed by sleep study within 12 months. No PAP/CPAP trial required. Obesity (BMI >= 30) required — lower BMI threshold with comorbidity does not apply to this indication. Continuation requires >=10% weight loss after 12 months AND OSA symptom stability. Initial authorization is 12 months (same as non-formulary exception reviews).

Policy effective April 1, 2026 · verified June 3, 2026 · source: 5.01.621.pdf