Medicare may cover Eli Lilly’s Zepbound for sleep apnea: Department of Health and Human Services agency
An injection pen of Zepbound, Eli Lilly’s weight loss drug, is on display in New York City on December 11, 2023.
Brendan McDermid | Reuters
Medicare drug plans can now cover Eli LillyBlockbuster obesity drug Zepbound for obstructive sleep apnea was confirmed by CNBC on Wednesday.
This opens the door for broader access to Zepbound, which is not currently covered by Medicare and many other weight loss insurance plans. Demand for the shot has surged in the last year, even though the price before insurance is about $1,000 a month.
In a statement to CNBC, a spokesperson for the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services, said that “current Medicare Part D and Medicaid coverage rules apply” to Zepbound following its landmark approval in December. the most common sleep-related breathing disorder.
Medicare Part D plans can only cover obesity medications if they are used for another medically accepted purpose approved by the Food and Drug Administration, the CMS spokesman said, citing the agency’s guidance. The spokesperson added that Part D plans could consider using prior authorization – a process in which a provider must first obtain approval from an insurer – for these drugs to ensure they are for that specific purpose be used.
The FDA approved Zepbound on Dec. 20 for patients with obesity and moderate to severe forms of obstructive sleep apnea (OSA), which refers to pauses in breathing during sleep due to narrowed or blocked airways. According to Eli Lilly, Zepbound was the first drug treatment approved for the estimated 20 million people with these forms of the disease.
Medicare Part D plans may also provide coverage Novo NordiskWegovy, the weight-loss drug from , has another approved purpose: reducing cardiovascular risk. Wegovy and Zepbound’s diabetes counterparts — Ozempic and Mounjaro, respectively — are covered by Medicare and most insurance plans.
Both Novo Nordisk and Eli Lilly are studying their weight loss drugs to treat fatty liver disease, chronic kidney disease, sleep apnea and more. To be covered, these drugs would need to have late-stage trial results and then seek FDA approval for these uses.
Meanwhile, state Medicaid coverage for Zepbound and other obesity medications depends on what condition they are prescribed for and whether their manufacturer has signed a specific Medicaid drug reimbursement agreement, the spokesman said.
Under this agreement with the Secretary of Health and Human Services, manufacturers agree to provide rebates to states in exchange for Medicaid coverage of their drugs. The states share the rebates with the federal government.
A state Medicaid program must cover Zepbound if it is prescribed for OSA and Eli Lilly has signed the Medicaid drug rebate agreement, the spokesman said.
However, if Zepbound is prescribed for weight loss, state Medicaid programs are not required to cover the cost.
The Biden administration proposed a rule in November that would allow Medicare and Medicaid to cover weight loss medications for patients with obesity. The rule would give millions of people access to weekly injections, but would cost taxpayers up to $35 billion over the next decade.
It’s unclear whether President-elect Donald Trump’s administration will keep the rule in place.
