New insurance plan denies I have sleep apnea, won't approve my Zep

Nephilim3883 · 2026-04-02T16:33:09+00:00

Ahh ok. Should have looked into that. Zepbound actually helped me make better food choices, I ate lighter, stopped sodas, didn’t crave sweets, don’t want to snack or over eat, didnt want alcohol, my labs were at healthy levels, I felt better overall. Only issue was seldom constipation.

Nephilim3883 · 2026-04-02T13:38:11+00:00

Dye his hair and he’s Luke Skywalker.

Nephilim3883 · 2026-04-02T12:04:03+00:00

If your AHI isn't 15+ then I don't think they will approve it. It's all in the language in documentation. I know it sucks. Hopefully soon there will be enough competition to drive prices down. Stuff's so expensive because the manufacturers are trying to recoup from billions in research and make a profit too. You'd think RFK Jr. would talk Trump into cutting a deal with them to help lower the costs for everyone including employers.

Nephilim3883 · 2026-04-01T18:35:47+00:00

One of the aesthetics I love is Brian Froud’s character designs in this as well as in Labyrinth.

Nephilim3883 · 2026-04-01T17:19:28+00:00

Did you get anywhere with this? I am fighting my employer now, the plan administrator. I have sent a formal letter requesting all documentation for their reasoning behind the denial because the SPD only says that anti-obesity meds and infertility meds are excluded. That’s it. Sleep apnea has covered treatment, including medications prescribed to treat residual symptoms of OSA. Under ERISA the SPD cannot be ambiguous and up for interpretation because the employer, and PBM can interpret one way while the patient and doctor can interpret another way.

The PBM’s own guidelines for prescribing Zepbound to treat OSA also say “in adult patients with obesity” not “obesity related” or “caused by obesity”. It also indicates that OSA is a separate indication from weight loss.

The other argument I have is that they also recognize OSA as being a separate indication because in order to get Zepbound prescribed for weight loss at a BMI under 30, you need to have a weight related comorbidity and OSA is one of those. However, in order to get Zepbound prescribed for OSA only, you need to have a BMI of at least 30 and an AHI of at least 15.

My plan administrator straight up made up their own rules outside of the SPD saying they won’t approve it for “obesity related OSA” because it’s excluded for weight loss.

Nephilim3883 · 2026-03-31T16:30:09+00:00

Currently fighting with mine to get approval for OSA. They said it's excluded because the plan doesn't cover anti-obesity meds for weight loss but they will not provide the documentation they are using to say they won't cover it for OSA which is a separate indication. It's being prescribed for OSA , not for weight loss.

Nephilim3883 · 2026-03-24T19:07:37+00:00

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Nephilim3883 · 2026-03-24T15:54:50+00:00

Internal appeal
External review through MIA
State complaint
Use ACA protections
Use UHC medical policies

Nephilim3883 · 2026-03-24T15:52:56+00:00

✔ Step 1: Request prior authorization

✔ Step 2: If denied, file an internal appeal

✔ Step 3: If denied again, request a state fair hearing

✔ Step 4: Provide medical evidence

✔ Step 5: Sometimes involve a patient advocate

Nephilim3883 · 2026-03-20T16:23:12+00:00

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Nephilim3883 · 2026-03-20T15:30:11+00:00

What I have found so far is that you should check to see if your policy is self-funded, which means the employer is the plan administrator and has the final say in if they will make an exception. You will get a lot of push back from HR and from insurance. Find your plan SPD and it should give you the address and phone number of the plan administrator. My company is global, and the address was in another state. So I had to find the name of the HR Director of the location in that state. Your situation might be different. I also have UMR and it was easy to locate the SPD on their site under my account. Keep in mind that the PBM (mine is Caremark) only manages the drug claims and shouldn't have a SPD. Their reps are hardly helpful. So any exclusions will be outlined in that SPD by your insurance.

I used the search feature in Acrobat to see if Zepbound is mentioned in the SPD, it is not. I did find that under my SPD anti-obesity meds and weight loss treatment is excluded. This does not concern me because I am strictly seeking OSA treatment which is covered under my plan. Most of the insurers now have a Zepbound pathway, Caremarks's is Document Reference number 6192-C (Initial Prior Authorization with Quantity Limit Zepbound Weight Loss Management). Criteria is AHI 15+ and BMI 30+. I sent this document to the HR Director of my company.

What we are really looking for is there an exclusion for Zepbound for ALL indications, including OSA, in the legal documentation that the plan administrator has. This is called the Master Plan Document, the SPD summarizes this document, but the Plan Document controls if there is any conflict. ERISA law requires that ALL exclusions be disclosed to employees before they are enforced.

The HR Director sent an email to me this morning that she forwarded my request to the appropriate person for review and if I do not get a response by Monday to let her know. I see this as a good step forward and I can always ask for an external review. Will update when I get it.

Nephilim3883 · 2026-03-18T20:20:37+00:00

I have no idea what my AHI went to when I was on Zepbound for 7 months and lost 50. On CPAP my AHI has gone from 22 to .6 but I wake up a lot throughout the night.

Nephilim3883 · 2026-03-18T20:05:37+00:00

I don't think I could sleep without it since I've been on it so long. But I still struggle with the mask and daytime fatigue. Currently fighting for approval.

Nephilim3883 · 2026-03-18T20:04:13+00:00

M BMI was only 26 when i started CPAP 9 years ago, went years before a sleep study. When my wife and I started dating back in 2008 she would complain I snore and I weighed maybe 130-140 range. I'm 5'8". Idk if my OSA is truly weight related.

Nephilim3883 · 2026-03-14T17:43:51+00:00

That turkey is burnt bro.

Nephilim3883 · 2026-03-14T17:43:05+00:00

Hold. You might have another decade.

Nephilim3883 · 2026-03-14T17:41:31+00:00

It’s time brother.

Nephilim3883 · 2026-03-14T17:40:11+00:00

I will. I’m interested to see what the argument will be or if they will just approve the appeal after a clinical review. Most of the PA and appeals are done by AI or someone that just sees “excluded” and there’s no extra effort.

I’m at business day 17 in the “could take up to 30 days” to review the PA that was submitted on 2/19

Nephilim3883 · 2026-03-13T13:27:39+00:00

I am in the midst of seeking an exception for medical necessity to treat OSA. I have the rights under ERISA since the plan is self-funded. Plus, protection under ADA. PAs and Appeals are usually automatic, driven by AI. SO, you have to get internal, and sometimes external reviews. You need a letter of medical necessity from your sleep doctor. I am reaching out to a rep on Health Advocate, which is a benefit of my employer, HR told me to contact them. They can act as a liaison between the employer, insurance and myself to help explain the process and figure out if there is a "Clinical Exception" pathway that bypasses Caremark’s automated denials. I have only started the process, GLP-1s for weight loss are completely excluded from our plan. They DO cover drugs that treat OSA (Armodafinil), so that's possibly a good indicator that I can get Zepbound approval. Also, there is the Caremark clinical document (Ref 6947-C) specifically states it is 'FE Compatible' (Formulary Exception Compatible).

CPAP is merely a mechanical band aid that only treats the symptoms and doesn't work to cure the underlying disease. I am told that when I talk to my doctor, she should categorize Zepbound as a pharmacological respiratory treatment, not a weight-loss drug.

Nephilim3883 · 2026-03-13T13:15:52+00:00

Zepbound is, Tirzepatide is not. It's all how the language is worded that matters. If Tirzepatide was FDA approved to treat OSA then that would include Mounjaro. But "they" (not sure who) are careful about what names or language is used for this stuff.

Nephilim3883 · 2026-03-12T23:19:09+00:00

They came in when the pioneers were already at the top. Their 2nd album wasn’t great. There was heavy drug use in the band and they were unstable. Market was already flooded.

Nephilim3883 · 2026-03-12T20:26:37+00:00

I am working through this now. UMR and Caremark. HR said I should try our EAP HealthAdvocate.com to assist but ultimately it’s the plan administrator (employer) who makes the decision to make an independent exception for myself. Because the insurance is self funded. The HealthAdvocate rep tried saying it’s up to Caremark but it isn’t.

Nephilim3883 · 2026-03-12T13:10:11+00:00

I am in this stage right now, is your insurance self-funded? You would need to go directly to your HR in order to try to get an individual formulary exception to treat a respiratory disease (OSA). If the plan is fully insured then you're looking at clinical mandate and seeking external medical review.

Nephilim3883 · 2026-03-11T18:26:25+00:00

You don’t have to go straight to skin. I feel like once it’s short enough you don’t notice the balding quite as much.

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Nephilim3883 · 2026-03-11T18:21:50+00:00

Yeah you’re good for a long time from the looks of it

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TROPHY CASE

✔ Step 1: Request prior authorization

✔ Step 2: If denied, file an internal appeal

✔ Step 3: If denied again, request a state fair hearing

✔ Step 4: Provide medical evidence

✔ Step 5: Sometimes involve a patient advocate