Medicare can now cover Eli Lilly’s Zepbound for sleep apnea, CMS says

Medicare drug plans can now cowl Eli Lilly‘s blockbuster weight problems drug Zepbound for obstructive sleep apnea, CNBC confirmed on Wednesday. 

That opens the door for broader entry to Zepbound, which isn’t at present lined by Medicare and plenty of different insurance coverage for weight reduction. Demand for the injection has soared over the past 12 months regardless of its roughly $1,000 price tag earlier than insurance coverage.

In an announcement to CNBC, a spokesperson for the Facilities for Medicare & Medicaid Companies mentioned “present Medicare Half D and Medicaid protection guidelines apply” to Zepbound following its landmark approval final month for the commonest sleep-related respiration dysfunction.

Medicare Half D plans can solely cowl weight problems medication if they’re used for an additional medically accepted purpose accredited by the Meals and Drug Administration, the CMS spokesperson mentioned, referring to the company’s guidance. The spokesperson added that Half D plans could think about using prior authorization – a course of the place a supplier should first get approval from an insurer – for these medication to make sure they’re getting used for that particular goal. 

The FDA on Dec. 20 cleared Zepbound for sufferers with weight problems and moderate-to-severe types of obstructive sleep apnea, or OSA, which refers to respiration interrupted throughout sleep as a result of narrowed or blocked airways. That made Zepbound the primary drug remedy cleared for the estimated 20 million folks with these types of the illness, in response to Eli Lilly.

Medicare Half D plans are equally allowed to cowl Novo Nordisk‘s weight reduction drug Wegovy for its other approved use of reducing cardiovascular dangers. The diabetes counterparts of Wegovy and Zepbound – Ozempic and Mounjaro, respectively – are lined by Medicare and most insurance coverage. 

Each Novo Nordisk and Eli Lilly are learning their weight reduction medicines as remedies for fatty liver illness, continual kidney illness, sleep apnea and extra. To be lined, these medication would wish to return late-stage trial outcomes after which be submitted for FDA approval for these makes use of.

In the meantime, state Medicaid protection for Zepbound and different weight problems drugs relies on what situation they’re prescribed for and whether or not their producer has signed a sure Medicaid drug rebate agreement, in response to the spokesperson. 

Underneath that settlement with the secretary of Well being and Human Companies, producers agree to offer rebates to states in alternate for Medicaid protection of their medication. States share the rebates with the federal authorities. 

A state Medicaid program should cowl Zepbound whether it is prescribed for OSA and Eli Lilly has signed the Medicaid drug rebate settlement, the spokesperson mentioned. 

But when Zepbound is prescribed for weight reduction, state Medicaid packages are usually not required to cowl it. 

The Biden administration in November proposed a rule that may permit Medicare and Medicaid to cowl weight reduction medication for sufferers with weight problems. The rule would give thousands and thousands of individuals entry to weekly injectables, however it might price taxpayers as a lot as $35 billion over the following decade.

It’s unclear if President-elect Donald Trump’s administration will pursue the rule.