An injection pen for Eli Lilly’s weight loss drug Zepbound is on display in New York City on December 11, 2023.
Brendan McDiarmid | Reuters
Now covered by Medicare drug plans Eli Lilly‘s blockbuster obesity drug Zepbound is effective against obstructive sleep apnea, CNBC confirmed Wednesday.
This opens the door to broader access to Zepbound, which is currently not covered by Medicare or many other weight loss insurance plans. Demand for the shots has soared over the past year, even though they cost about $1,000 a month before insurance.
A spokesperson for the Centers for Medicare and Medicaid Services, an agency of the U.S. Department of Health and Human Services, said in a statement to CNBC that Zepbound, which received groundbreaking approval in December, “does not currently support Medicare Part D and Medicaid. The applicable provisions shall apply.” The most common sleep-related breathing disorder.
A CMS spokesperson cited Food and Drug Administration guidance stating that Medicare Part D plans only cover obesity drugs if used for an additional medically acceptable purpose approved by the Food and Drug Administration. He said he could. The spokesperson said Part D plans require prior authorization (a process in which health care providers must first obtain approval from the insurance company) to ensure that those drugs are used for a specific purpose. He added that there is a possibility of considering the use of
On December 20, the FDA approved approval of Zepbound for patients with obesity and moderate to severe obstructive sleep apnea (OSA). OSA refers to interruptions in breathing during sleep due to narrowing or obstruction of the airways. Eli Lilly says this makes Zepbound the first drug treatment approved for the estimated 20 million people with these conditions.
Medicare Part D plans are similarly allowed to cover: novo nordiskThe weight loss drug Wegovy has been approved for another use: reducing cardiovascular risk. Wegovy and Zepbound’s diabetes equivalents (Ozempic and Mounjaro, respectively) are covered by Medicare and most insurance plans.
Both Novo Nordisk and Eli Lilly are investigating weight loss drugs as treatments for fatty liver disease, chronic kidney disease, sleep apnea, and more. To be eligible, these drugs must submit late-stage trial results and then apply for FDA approval for their use.
Meanwhile, state Medicaid coverage for Zepbound and other obesity drugs depends on what conditions they are prescribed for and whether the manufacturer signs a specific Medicaid drug rebate agreement, a spokesperson said. It is said that it depends on whether the
Under an agreement with the Secretary of Health and Human Services, manufacturers agree to provide rebates to states in exchange for Medicaid coverage of their drugs. Each state shares the rebate with the federal government.
If Zepbound is prescribed for OSA and Eli Lilly signs a Medicaid drug rebate agreement, the state’s Medicaid program must cover Zepbound, the spokesperson said.
However, if Zepbound is prescribed for weight loss, your state’s Medicaid program does not have to cover it.
In November, the Biden administration proposed a rule that would allow Medicare and Medicaid coverage of weight loss drugs for obese patients. The rule would give millions of people access to weekly shots, but it would cost taxpayers up to $35 billion over the next 10 years.
It’s unclear whether President-elect Donald Trump’s administration will pursue the rule.