
Sleep Apnea Takes Zepbound from No to Maybe in Medicare
Last week we got another glimpse of incremental progress in coverage for obesity medicines in health insurance plans. CMS announced that Medicare drug plans (Part D or Medicare Advantage) could now cover Zepbound (tirzepatide) when doctors prescribe it to patients for obesity and sleep apnea. This is not the opening of floodgates. It is movement from an absolute “no” to “maybe.” If the patient has both obesity and sleep apnea and if the drug plan so chooses, then maybe a Medicare patient can get it covered.
Inching Toward Taking Obesity Seriously
This is all part of slowly overcoming deep bias about obesity and the people who live with it. The norm of regarding this condition of a mere behavioral problem – not a real, chronic disease – is so deep that everyone defaults to think the indication for obesity medicines is simply weight loss. Not a real medical condition.
Even in new drug development guidance, FDA is still saying claims for these drugs “will generally be limited to weight reduction.” Indications for the real medical need – preventing or easing the complications of untreated obesity – are add-ons. This is the case for Wegovy (semaglutide), which gained a cardiovascular indication last year. This is what Lilly accomplished with its recent sleep apnea approval for Zepbound.
Incremental progress. For both Wegovy and Zepbound, it brought a quick nod from CMS for the possibility to cover these drugs in the Medicare population.
More to Come
Further progress for these drugs in Medicare coverage is sure to come. The biggest win could come for the new administration to go forward with treating these drugs as medicines for obesity and opening up both Medicare and Medicaid coverage. This is what CMS proposed late last year. We all have an opportunity to comment and urge the new administration to claim this victory.
But even if CMS punts, both Lilly and Novo Nordisk are working on more indications. Kidney disease, heart failure, liver disease, and osteoarthritis are all potential indications that could open the door wider for coverage of these medicines. Slow but sure progress is coming.
Click here, here, and here for more on this move to open Medicare a bit for Zepbound.
Pensive Young Woman Leaning on Her Elbow, painting by Pierre-Auguste Renoir / WikiArt
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January 12, 2025
January 12, 2025 at 8:26 pm, Michael Jones said:
I’ve had Zepbound approved for 2 Medicare patients already late last week.
January 13, 2025 at 3:22 am, Ted said:
Encouraging news. Thanks, Michael!
January 14, 2025 at 1:02 pm, David Garcia said:
I just got diagnosed with the severe sleep appnea and I’m over weight but I’m still trying to get it covered I was on Mounjaro and the insurance stopped covering it now I’m gaining weight again and I can’t get the help what’s wrong with this government
January 15, 2025 at 5:10 am, Ted said:
Press on. Appeal and insist.
January 15, 2025 at 7:39 am, Margaret Jewitt said:
I was prescribed Zepbound and I have United healthcare. They may approve it, but it is tier 5 or six so it will cost around $500 per month who can afford that on a fixed income.
January 16, 2025 at 3:36 am, Ted said:
And the thing is that they may well charge you a copay that is higher than the net price they pay for the drug. It is happening:
https://conscienhealth.org/2024/12/exploiting-people-with-obesity-through-abusive-copays/
January 16, 2025 at 9:11 am, Kay said:
I was recently approved for Zepbound for sleeping apnea through my medicare advantage plan. I have Neuropathy and RSD in legs and arm and have had Rectal cancer with 4 surgeries in2 years,an ileostomy and reversal, 2 different chemotherapy, radiation!! All this has caused weight issues, I swimming regularly and eat healthy. But can’t eat many vegetables since ileostomy, so it’s a real struggle. I had to pay $699 for my 1st month copay,RIDICULOUS!!! AND 25% after every month!! It’s REALLY SAD DRUG ADDICTS GET FREE NARCAN in case they overdose by their OWN FREE WILL!!! EVEN DIABETICS HAVE TO PAY A HIGHER COPAY. THERE’S SOMETHING REALLY WRONG WITH THIS COUNTRY!!!