Medicare drug plans can now cover Eli Lillyis the blockbuster anti-obesity drug Zepbound because of obstructive sleep apnea, CNBC confirmed Wednesday.
This opens the door for broader access to Zepbound, which shouldn’t be currently covered by Medicare and lots of other weight reduction insurance policy. Demand for the shot has skyrocketed over the past 12 months despite average demand Price tag of $1,000 per 30 days before the insurance.
In an announcement 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. groundbreaking approval in December due to essentially the most common sleep-related respiration disorder.
Medicare Part D plans can only cover obesity medications in the event that they are used for an extra medically approved purpose approved by the Food and Drug Administration, the CMS spokesman said, citing the agency Instructions. The spokesperson added that Part D plans could think about using prior authorization – a process during which a provider must first obtain approval from an insurer – for these drugs to make sure they’re for that specific purpose be used.
The FDA approved Zepbound on Dec. 20 for patients with obesity and moderate to severe types of obstructive sleep apnea (OSA), which refers to pauses in respiration during sleep because of narrowed or blocked airways. According to Eli Lilly, Zepbound was the primary drug treatment approved for the estimated 20 million individuals with these types of the disease.
Medicare Part D plans can also provide coverage Novo NordiskWegovy, the burden loss drug, is thought for this other approved use: Reducing cardiovascular risk. Wegovy and Zepbound's diabetes counterparts — Ozempic and Mounjaro, respectively — are covered by Medicare and most insurance policy.
Both Novo Nordisk and Eli Lilly are studying their weight reduction drugs to treat fatty liver disease, chronic kidney disease, sleep apnea and more. To be covered, these drugs would want to have late-stage trial results after which seek FDA approval for these uses.
Meanwhile, federal Medicaid coverage for Zepbound and other obesity medications is determined by what condition they’re prescribed for and whether their manufacturer has signed a particular agreement Medicaid drug discount agreementsaid the speaker.
Under this agreement with the Secretary of Health and Human Services, manufacturers conform 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 whether 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 reduction, state Medicaid programs should not required to cover the fee.
The Biden administration in November suggested a provision that may allow Medicare and Medicaid to cover weight reduction medications for patients with obesity. The rule would give thousands and thousands of individuals access to weekly injections, but would cost taxpayers as much as $35 billion over the subsequent decade.
It's unclear whether President-elect Donald Trump's administration will keep the rule in place.
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