Medicare Drug Plans Can Now Cover Eli Lilly’s Zepbound for Obstructive Sleep Apnea
Medicare drug plans can now cover Eli Lilly’s blockbuster obesity drug Zepbound for the treatment of obstructive sleep apnea, CNBC has confirmed. This opens the door for broader access to Zepbound, which is currently not covered by Medicare and many other insurance plans for weight loss. The injection’s price tag is around $1,000 per month, despite high demand from patients.
The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare Part D and Medicaid coverage rules apply to Zepbound following its landmark approval in December for the most common sleep-related breathing disorder, obstructive sleep apnea. Medicare Part D plans can only cover obesity drugs for an additional medically accepted purpose approved by the Food and Drug Administration (FDA).
Prior authorization may be required for these drugs to ensure they are being used for the specific purpose. The FDA approved Zepbound for patients with obesity and moderate-to-severe forms of obstructive sleep apnea in December, making it the first drug treatment cleared for the estimated 20 million people with these forms of the disease.
Medicare Part D plans are permitted to cover Novo Nordisk’s weight loss drug Wegovy for its other approved use, lowering cardiovascular risks. Similarly, Medicare and most insurance plans cover the diabetes counterparts of Wegovy and Zepbound, Ozempic and Mounjaro, for their approved uses, but lack of coverage for weight loss.
State Medicaid coverage for Zepbound and other obesity medications depends on the condition they are prescribed for and whether their manufacturer has signed a Medicaid drug rebate agreement. If the drug is prescribed for OSA and Eli Lilly has signed the agreement, the state Medicaid program must cover it. However, if the drug is prescribed for weight loss, state Medicaid programs are not required to cover it.
The Biden administration recently proposed a rule that would allow Medicare and Medicaid to cover weight loss drugs for patients with obesity, potentially giving millions of people access to weekly injectables, but this would cost taxpayers as much as $35 billion over the next decade. It is unclear if the Trump administration will pursue this rule.