Medicare Covers Zepbound for Sleep Apnea

Medicare Now Covers Eli Lilly’s Zepbound for Obstructive Sleep Apnea

Medicare drug plans can now cover Eli Lilly’s blockbuster obesity drug Zepbound for obstructive sleep apnea, CNBC confirmed on Wednesday.

Broader Access to Zepbound

The news opens the door for broader access to Zepbound, which is not currently covered by Medicare and many other insurance plans for weight loss. Demand for the injection has soared over the last year, despite its roughly $1,000 per month price tag before insurance.

Background on Zepbound

Zepbound was approved by the FDA in December for patients with obesity and moderate-to-severe forms of obstructive sleep apnea, or OSA, which refers to breathing interrupted during sleep due to narrowed or blocked airways. The FDA clearance made Zepbound the first drug treatment cleared for the estimated 20 million people with those forms of the disease, according to Eli Lilly.

Medicare Coverage

In a statement to CNBC, a spokesperson for the Centers for Medicare & Medicaid Services (CMS) said, "current Medicare Part D and Medicaid coverage rules apply" to Zepbound following its landmark approval. Medicare Part D plans can only cover obesity drugs if they are used for an additional medically accepted purpose approved by the FDA. The spokesperson added that Part D plans may consider using prior authorization – a process where a provider must first get approval from an insurer – for those drugs to ensure they are being used for that specific purpose.

Novo Nordisk’s Wegovy

Medicare Part D plans are similarly allowed to cover Novo Nordisk’s weight loss drug Wegovy for its other approved use: lowering cardiovascular risks. The diabetes counterparts of Wegovy and Zepbound – Ozempic and Mounjaro, respectively – are covered by Medicare and most insurance plans.

State Medicaid Coverage

State Medicaid coverage for Zepbound and other obesity medications depends on what condition they are prescribed for and whether their manufacturer has signed a certain Medicaid drug rebate agreement. Under that agreement with the secretary of Health and Human Services, manufacturers agree to provide rebates to states in exchange for Medicaid coverage of their drugs. States share the rebates with the federal government.

Proposed Rule for Weight Loss Drugs

The Biden administration in November proposed a rule that would allow Medicare and Medicaid to cover weight loss drugs for patients with obesity. The rule would give millions of people access to weekly injectables, but it would cost taxpayers as much as $35 billion over the next decade. It is unclear if President-elect Donald Trump’s administration will pursue the rule.

Conclusion

The coverage of Zepbound by Medicare and potentially other insurance plans is a significant development in the treatment of obstructive sleep apnea. As the demand for the drug continues to grow, it is likely that more people will have access to this treatment option.

FAQs

Q: What is Zepbound?
A: Zepbound is a weight loss drug approved by the FDA for patients with obesity and moderate-to-severe forms of obstructive sleep apnea.

Q: What is the current coverage status of Zepbound?
A: Zepbound is not currently covered by Medicare and many other insurance plans for weight loss, but it can be covered for obstructive sleep apnea.

Q: What is the price of Zepbound?
A: The price of Zepbound is roughly $1,000 per month before insurance.

Q: Is there a proposed rule for weight loss drugs?
A: Yes, the Biden administration proposed a rule that would allow Medicare and Medicaid to cover weight loss drugs for patients with obesity.