GLP-1s and the Evolving Sleep Apnea Landscape
Obstructive sleep apnea (OSA) is a prevalent yet underdiagnosed condition affecting millions worldwide. People with OSA are subject to sudden drops in blood oxygenation levels that can lead to severe cardiovascular, metabolic, and cognitive consequences if the condition remains untreated. Traditionally, OSA has been managed through personal appliances that apply continuous positive airway pressure (CPAP). Although CPAP machines are considered the gold standard of care, patient adherence remains a major challenge due to their relative discomfort and inconvenience.
Oral appliances, such as mandibular advancement devices, provide relief for mild-to-moderate cases, but are less effective for those with severe OSA. While there are a few surgical interventions available, including uvulopalatopharyngoplasty (UPPP) and hypoglossal nerve stimulation, these procedures are invasive and not always successful.
Weight management programs are also a key component of OSA treatment, as obesity is a primary risk factor; however, lifestyle interventions are difficult for patients to sustain. For the past several years, there has been a significant unmet need for OSA patients who cannot tolerate CPAP machines and do not achieve meaningful symptom relief from other interventions.
GLP-1s: A Game-Changer in OSA Treatment
Given the immense popularity of GLP-1 receptor agonist medications to treat both diabetes and obesity, the industry has been waiting to see how these medications’ expansions into obesity comorbidities will be received. Last spring, Novo Nordisk’s Wegovy (semaglutide) was approved to reduce the risk of major adverse cardiovascular events (MACE) in obese adults with established cardiovascular disease.
In December 2024, Eli Lilly’s Zepbound (tirzepatide) received FDA approval for OSA treatment, which represents a significant advancement in therapy. Originally developed for diabetes, GLP-1 receptor agonists have shown substantial effectiveness in promoting weight loss and enhancing metabolic health. As a result, they improve airway function and reduce apnea severity.
In addition to helping patients lose weight, Zepbound specifically decreases the fatty deposits around the airway that exacerbate OSA. Unlike CPAP and surgical options, it provides a pharmacologic alternative that improves adherence and supports long-term treatment success.
In January 2025, the MMIT Index team surveyed payers representing commercial, Medicare, and Medicaid lives to gather insights into the potential impact of GLP-1 drugs’ anticipated expansions into indications like OSA.
Payer Strategies for GLP-1s Used to Treat Obesity Comorbidities
The FDA approval of Zepbound for OSA is expected to impact coverage and management strategies across the payer landscape. According to the Q1 2025 MMIT Index Survey, 90% of payers expect to revise their coverage policies once expanded approvals for conditions such as high blood pressure, sleep apnea, and metabolic dysfunction-associated steatohepatitis (MASH) are granted. They plan to align these policy updates with the FDA’s approvals.
Furthermore, most payers anticipate tightening prior authorization (PA) requirements, utilization management, and step therapy protocols to control the potential surge in demand for GLP-1 following its approval for multiple indications.
Nearly half of surveyed payers plan to differentiate the PA process for GLP-1s based on indication, by excluding coverage for obesity and allowing restricted coverage for comorbidities. As one payer wrote, “Our organization currently does not cover medications used solely for weight loss, and the obesity comorbidities are handled using our medical exception criteria that we internally develop for each expanded indication.”
Commercial Plans: Commercial insurers have traditionally been cautious about covering high-cost medications, especially those related to weight management. However, the approval of Zepbound for OSA is likely to prompt a reassessment of their overall GLP-1 coverage policies. Insurers may implement utilization management strategies, like prior authorizations, to ensure appropriate use. These strategies might likely require documentation of an OSA diagnosis confirmed by sleep studies and evidence of previous unsuccessful standard treatments before approving Zepbound.
Employer Plans: Employers are also playing a significant role in the coverage of GLP-1s due to the high consumer demand for these products. Employers are in a unique position to consider how inclusion of these “lifestyle” brands can satisfy their enrollees and ultimately support their business. In a recent survey with MMIT’s employer panel, employers shared the factors they are considering when making coverage decisions for GLP-1s. Although some employers are making decisions based on underlying costs, many indicated that their primary rationale for providing coverage is the frequency of employee requests and the need to support overall health outcomes.
Medicare Plans: Historically, Medicare Part D has not covered medications prescribed solely for weight loss. However, with Zepbound’s OSA approval, Medicare drug plans are now authorized to cover Zepbound when prescribed for obese patients who also have this specific indication. This policy shift aligns with Medicare’s approach to cover treatments that address significant medical conditions beyond weight management.
Medicaid plans: Medicaid policies vary by state, with some states covering Zepbound under existing obesity treatment frameworks, and others imposing strict utilization management controls. Some states may require step-therapy protocols which mandate prior CPAP trials or weight management program participation before approval. Given Medicaid’s focus on cost containment, several states have entered negotiations for value-based contracts with manufacturers to offset costs, particularly in states with high OSA prevalence.
Future Implications for OSA Coverage
The long-term implications of Zepbound’s approval for OSA could reshape payer strategies and patient access. If real-world data confirms sustained improvements in OSA symptoms and cardiovascular outcomes, payers may broaden coverage beyond high-severity cases. Large employers may advocate for broader coverage due to the productivity benefits of treating OSA effectively.
If Zepbound reduces hospitalizations, cardiovascular events, and other costly complications of untreated OSA, payers may loosen restrictions over time. As new GLP-1 receptor agonists enter the market for OSA treatment, pricing pressure may lead to more competitive reimbursement models and broader payer adoption.
In conclusion, the FDA approval of Zepbound for OSA represents a paradigm shift in sleep apnea treatment. By offering a non-invasive, highly effective alternative to CPAP and surgery, Zepbound has the potential to disrupt the traditional OSA treatment landscape. However, payers will remain cautious by implementing strict utilization controls and cost-containment strategies before expanding coverage broadly.
Over time, as real-world evidence accumulates and long-term economic benefits are revealed, GLP-1 therapies could potentially become a mainstay in OSA treatment. The ongoing collaboration between payers, providers, and manufacturers will be essential in ensuring equitable access while maintaining cost sustainability in this rapidly evolving space.
Want to learn more? Our MMIT Indices solutions can provide a deep dive into specific therapeutic areas, including analysis of disruptive events.
