Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Authorization – Zepbound for OSA
All of:
- Treatment requested for obstructive sleep apnea
- Patient is 18 years of age or older
- BMI ≥ 30 kg/m2 documented in medical records
- Moderate-to-severe OSA evidenced by sleep study AND (AHI > 15 events/hour OR REI > 15 events/hour OR RDI > 15 events/hour)
- At least one previous unsuccessful dietary effort to lose weight documented
- Used in combination with a reduced calorie diet and increased physical activity
- No diagnosis of diabetes AND HbA1c ≤ 6.5%
- Provider attests patient counseled on appropriate positional therapy
- Provider attests patient counseled on avoidance of alcohol and/or sedatives before bedtime
- Prescriber attests no planned surgery for sleep apnea or obesity
- Prescriber attests no diagnosis of predominant central or mixed sleep apnea (mixed/central apneas/hypopneas > 50% of all respiratory events)
- Prescribed by or in consultation with a sleep specialist
Plus any one of:
- Patient has continued symptoms of OSA despite PAP therapy adherence (≥ 4 hours/night for ≥ 70% of nights)
- Patient is not a candidate for PAP therapy (e.g., upper airway anatomic abnormalities)
Reauthorization – On therapy < 52 weeks
All of:
- Patient has been on Zepbound for less than 52 weeks of consecutive therapy
- Medical records confirm any decrease from baseline in AHI, RDI, or REI after initiating Zepbound
- Weight loss ≥ 10% of baseline body weight
- Used in combination with a reduced calorie diet and increased physical activity
- No diagnosis of diabetes AND HbA1c ≤ 6.5%
- Patient continues to require treatment for obstructive sleep apnea
Reauthorization – On therapy ≥ 52 weeks
All of:
- Patient has been on Zepbound for ≥ 52 weeks of consecutive therapy
- Medical records confirm ≥ 50% decrease from baseline in AHI, RDI, or REI after initiating Zepbound
- Weight loss ≥ 10% of baseline body weight
- Used in combination with a reduced calorie diet and increased physical activity
- No diagnosis of diabetes AND HbA1c ≤ 6.5%
- Patient continues to require treatment for obstructive sleep apnea
Documentation to bring
- Medical records documenting BMI ≥ 30 kg/m2
- Sleep study results confirming moderate-to-severe OSA
- AHI > 15 events/hour OR REI > 15 events/hour OR RDI > 15 events/hour documented in sleep study
- Documentation of at least one previous unsuccessful dietary effort to lose weight
- Documentation of PAP therapy adherence failure (≥ 4 hours/night for ≥ 70% of nights with continued OSA symptoms) OR documentation that patient is not a candidate for PAP therapy
- HbA1c result confirming ≤ 6.5% and no diabetes diagnosis
- Prescriber attestation that patient was counseled on positional therapy
- Prescriber attestation that patient was counseled on avoidance of alcohol and/or sedatives before bedtime
- Prescriber attestation that patient has no planned surgery for sleep apnea or obesity
- Prescriber attestation that patient does not have predominant central or mixed sleep apnea
- Documentation of sleep specialist prescribing or consultation
- For reauthorization (< 52 weeks): Medical records showing any decrease from baseline in AHI, RDI, or REI
- For reauthorization (≥ 52 weeks): Medical records showing ≥ 50% decrease from baseline in AHI, RDI, or REI
- For reauthorization: Documentation of ≥ 10% weight loss from baseline body weight
Quantity limits
- all strengths — Supply limits may be in place (specific limits not defined in this document)
Approval and renewal
- Initial approval: 6 months
- Renewal: Requires ≥ 10% weight loss from baseline AND improvement in AHI, RDI, or REI from baseline. For patients on therapy < 52 weeks: any decrease in AHI/RDI/REI; renewal is 6 months. For patients on therapy ≥ 52 weeks: ≥ 50% decrease in AHI/RDI/REI from baseline; renewal is 12 months. Diabetes exclusion (no diabetes diagnosis and HbA1c ≤ 6.5%) is re-verified at continuation.
Not covered when
- Diagnosis of diabetes
- HbA1c > 6.5%
- Planned surgery for sleep apnea or obesity
- Predominant central or mixed sleep apnea (mixed/central apneas/hypopneas > 50% of all respiratory events)
Policy note: OSA severity is defined as AHI/REI/RDI > 15 events/hour (moderate-to-severe). PAP candidacy: patient must either have failed PAP therapy (defined as ≥ 4 hours/night for ≥ 70% of nights) with continued symptoms, or be documented as not a candidate for PAP. Reauthorization duration varies: 6 months if on therapy < 52 weeks; 12 months if on therapy ≥ 52 weeks. The 50% AHI/RDI/REI reduction threshold applies only at the ≥ 52-week renewal. The diabetes/HbA1c exclusion is re-verified at each reauthorization. Program number: 2025 P 1475-2. P&T Approval Dates: 3/2025, 12/2025. Effective Date: 3/1/2026.
Policy effective March 1, 2026 · verified June 2, 2026 · source: PA Non Formulary Zepbound · View policy document (PDF)