Zepbound can now be covered by Medicare
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El Lilly’s (LLY+1.91%) blockbuster weight-loss drug Zepbound is now eligible for Medicare coverage. The news could significantly expand access to the popular, yet costly treatment.
“With the recent change in the FDA [Food and Drug Administration] approved use for Zepbound (tirzepatide) to treat obstructive sleep apnea, current Medicare Part D and Medicaid coverage rules apply,” a Centers for Medicare & Medicaid Services (CMS) spokesperson told Quartz on Wednesday in an emailed statement.
The spokesperson added that Medicare Part D plans may add drugs to their formularies at any time during the plan year.
CMS rules prohibit coverage of weight-loss drugs for the sole use of losing weight, but guidance issued last March allows for anti-obesity medications approved “for an additional medically accepted indication” to be considered for coverage under that specific use.
Zepbound met that new criteria last month after the FDA approved it as the first prescription medication to address moderate-to-severe obstructive sleep apnea (OSA) in adults with obesity.
It now joins its rival, Novo Nordisk’s (NVO+2.42%) Wegovy, in gaining Medicare coverage. Wegovy, which contains the same active ingredient as Ozempic, became eligible after U.S. regulators expanded its approved use to include reducing heart risks in adults who are obese or overweight.
The newly expanded coverage could help many patients, as insurers have
been hesitant to cover these medications due to their high initial costs and uncertainty about long-term savings. Zepbound costs $1,086.37 per month without insurance.
The Biden-Harris administration proposed a new rule in November that would expand coverage of the anti-obesity medications for Medicare and Medicaid beneficiaries.
The proposal must still undergo the formal rule-making process, which could take several months, and would require endorsement from President-elect Donald Trump.
This complicates the issue since Trump has named Robert F. Kennedy Jr. to lead the U.S. Department of Health and Human Services, which oversees the Center for Medicare and Medicaid Services (CMS).
Kennedy has criticized the growing use of weight loss drugs. Instead, he has repeatedly promoted healthy eating as a solution to the country’s obesity epidemic.
