Eli Lilly’s obesity drug, Zepbound, is now covered by Medicare for patients with obstructive sleep apnea (OSA), following its FDA approval for this use on December 20, 2023. Prior to this, Zepbound, with a price tag around $1,000, was largely inaccessible to Medicare beneficiaries for weight loss. The Centers for Medicare & Medicaid Services (CMS) indicated that Medicare Part D plans can only cover obesity drugs for FDA-approved additional uses, necessitating prior authorization to ensure appropriate application. Zepbound is the first medication approved for treating the estimated 20 million individuals with moderate to severe OSA. Meanwhile, state Medicaid coverage for Zepbound varies; it is required if prescribed for OSA, contingent upon Eli Lilly’s participation in a Medicaid drug rebate agreement. If prescribed for weight loss, reimbursement becomes optional. The Biden administration’s recent proposal seeks to allow broader coverage for weight loss drugs, potentially impacting millions but costing taxpayers about $35 billion over the next decade. It remains uncertain whether the incoming Trump administration will advance this proposal. Overall, Zepbound’s expanded coverage could significantly enhance access to obesity treatment amid growing demand for effective weight loss solutions.
