Regence coverage for Zepbound (Osa)

Employer / Commercial Insurance

Depends on your plan's benefit

Coverage requires that the member benefit contract allows for coverage of medications for weight loss in obesity/overweight; OSA coverage is gated on the obesity/overweight weight loss benefit because Zepbound treats OSA mainly through weight loss per policy rationale

What you need to qualify

Age 18 and older
BMI of 30 or higher
6 months of a documented diet and exercise program
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

Qualification pathways

You can qualify through any one of these.

Moderate to severe OSA with obesity

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
Diagnosis of moderate to severe obstructive sleep apnea (AHI >= 15 events/hour)
Concurrent diagnosis of obesity (BMI >= 30 kg/m2)
Attestation medication will be used with lifestyle modification

Continuation of therapy - established on therapy prior to current health plan membership

All of:

Patient was established on therapy prior to current health plan membership
Documentation that medication was covered by another health plan
Clinical benefit such as disease stability
Member benefit contract allows coverage of medications for weight loss in obesity/overweight

Documentation to bring

Clinical documentation (e.g., chart notes) confirming diagnosis of moderate to severe OSA with AHI >= 15 events/hour
Clinical documentation of concurrent diagnosis of obesity (BMI >= 30 kg/m2)
Attestation that medication will be used with lifestyle modification
For continuation: attestation of improvement in signs and symptoms of OSA (sleep quality, daytime functioning, or AHI from baseline)

Quantity limits

all strengths — 4 pens per 28 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Attestation of improvement in signs and symptoms of OSA such as improvement in sleep quality, daytime functioning, or apnea-hypopnea index (AHI) from baseline. Member benefit contract coverage for weight loss in obesity/overweight re-verified at each renewal.

Not covered when

Central or mixed sleep apnea — considered investigational
Cheyne-Stokes respiration — considered investigational
OSA with major craniofacial abnormalities — considered investigational
Co-administration with other weight loss medications (Contrave, Qsymia, or other GLP-1 agents in this policy) considered investigational
Diabetic ketoacidosis (DKA)
Overweight (BMI 27-29.9) with OSA: must qualify under general Obesity/Overweight criteria (Section II.A.1) with OSA as a comorbidity, not under the OSA-specific criteria which requires BMI >= 30
Type 1 diabetes

Policy note: PAP/CPAP trial is NOT required before approval. Policy explicitly notes Zepbound treats OSA mainly through weight loss, therefore the member benefit contract weight loss coverage requirement applies. Policy note states: for overweight (BMI 27-29.9) with OSA as a comorbidity, patients should refer to the general Obesity/Overweight criteria (Section II.A.1), not the OSA-specific pathway. OSA-specific pathway requires BMI >= 30 (obesity) as a concurrent diagnosis.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

ACA Marketplace

Depends on your plan's benefit

Coverage requires that the member benefit contract allows for coverage of medications for weight loss in obesity/overweight. The policy states that Zepbound works for OSA mainly through weight loss, so the obesity/overweight benefit rider requirement applies.

What you need to qualify

Age 18 and older
BMI of 30 or higher
6 months of a documented diet and exercise program
Diagnosed obstructive sleep apnea (AHI of 15 or higher)

Qualification pathways

You can qualify through any one of these.

Moderate-to-severe OSA with obesity

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
Diagnosis of moderate to severe obstructive sleep apnea (AHI >= 15 events/hour)
Concurrent diagnosis of obesity (BMI >= 30 kg/m2)
Attestation that medication will be used with lifestyle modification

Documentation to bring

Clinical documentation (such as chart notes) confirming diagnosis of moderate to severe obstructive sleep apnea with AHI >= 15 events/hour
Clinical documentation confirming concurrent diagnosis of obesity (BMI >= 30 kg/m2)
Attestation that medication will be used with lifestyle modification
Verification that member benefit contract allows coverage of medications for weight loss in obesity/overweight

Quantity limits

all strengths — 4 pens/28 days

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Attestation of improvement in signs and symptoms of OSA such as improvement in sleep quality, daytime functioning, or apnea-hypopnea index (AHI) from baseline. Member benefit contract must continue to allow coverage for weight loss in obesity/overweight. Attestation required that medication will continue to be used with lifestyle modification.

Not covered when

Central or mixed sleep apnea — considered investigational
Cheyne-Stokes respiration — considered investigational
OSA with major craniofacial abnormalities — considered investigational
Overweight (BMI 27-29.9 kg/m2) with OSA: policy directs to obesity/overweight criteria (Section II.A.1) rather than the OSA-specific criteria which requires BMI >= 30
Co-administration with other medications for obesity or overweight (Contrave, Qsymia) is considered investigational
Type 1 diabetes

Policy note: OSA criteria for Zepbound were added to this policy effective 4/3/2025. PAP trial is NOT required prior to approval. The policy notes that standard of care for OSA includes PAP therapy (CPAP, APAP, BiPAP) and oral appliances, but does not require prior PAP failure. The OSA indication requires the weight loss benefit rider because the policy states Zepbound works for OSA mainly through weight loss. For overweight patients (BMI 27-29.9) with OSA as a comorbidity, coverage may be available under the general obesity/overweight criteria (Section II.A.1) rather than the OSA-specific pathway. AHI >= 15 events/hour defines moderate-to-severe OSA for purposes of this policy.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf