Zepbound and Medicare Coverage: What to Know

Medicare is currently prohibited by the federal government from covering Zepbound and other weight loss drugs such as Wegovy when used specifically as an anti-obesity medication. However The U.S. Food and Drug Administration (FDA) has approved an indication change that allows Zepbound to be used to treat obstructive sleep apnea (OSA).

? Zepbound and Medicare coverage

Zepbound contains the same active ingredient as Mounjaro which is already FDA-approved to treat type 2 diabetes. Some Medicare Part D plans may cover the costs of both drugs when a doctor prescribes them for reasons other than weight loss.

Medicare may cover Zepbound for people with moderate to severe obstructive sleep apnea (OSA), with Zepbound becoming the first OSA drug to receive FDA approval.

Coverage would fall under Medicare Part D prescription drug plans or Medicare Advantage (Part C) plans that include prescription drug coverage. Prior authorization and out-of-pocket costs may also apply. It is best to check your Medicare Part D plan’s formulary (drug list) to confirm coverage.

Zepbound now joins Novo Nordisk’s Wegovy in gaining Medicare coverage. Wegovy, which has the same active component as Ozempic, which qualified after its use was extended to include lowering cardiovascular risk in people who have obesity or are overweight.

? What is Zepbound?

Zepbound is the brand name of a drug containing the active ingredient tirzepatide. It is a prescription drug that has FDA approval for its role in chronic weight management, specifically targeting adults struggling with obesity or overweight conditions, with at least one weight-related health issue. This obesity drug is relatively new to the market, having received FDA (Food and Drug Administration) approval in November 2023. It is produced by the pharmaceutical giant Eli Lilly and Company.

Key characteristics of Zepbound:

• Administration and dosage: Zepbound is designed for patient convenience, administered via a weekly injection that can be self-administered at home. The starting dose is typically 2.5mg, which can be gradually increased monthly to a maximum of 15mg to suit individual patient needs
• Mechanism of action: As a dual-agonist medication, Zepbound works uniquely by activating two hormone receptors, GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 (glucagon-like peptide-1). This dual action not only aids in managing blood glucose levels, but also contributes to a feeling of satiety, helping patients eat less and potentially lose weight. By regulating appetite and food intake, Zepbound aims to help individuals feel fuller, reduce hunger, and experience fewer food cravings
• Clinical efficacy: In clinical trials, Zepbound has shown impressive weight loss outcomes. Non-diabetic patients using the highest dose experienced an average weight loss of 18%, with some individuals seeing a reduction in body weight of up to 26% over 88 weeks.

? How can Zepbound help with obstructive sleep apnea (OSA)?

What is sleep apnea?

OSA is a chronic condition in which the throat muscles relax during sleep causing airways to become partially or fully blocked. Breathing may be interrupted 15-29 times per hour during sleep with moderate OSA, or 30 or more times per hour with severe OSA.

Obesity and being overweight are major risk factors for OSA, particularly when the distribution of fat increases the circumference of the neck. Millions of Americans are estimated to suffer from this sleep disorder.

Zepbound has been shown to lower blood sugar levels, support weight loss, and improve sleep apnea symptoms, with two clinical trials, which showed that Zepbound was more effective than a placebo at reducing the severity of OSA in patients with obesity after a year.

Potential side effects of Zepbound

As with any medication, Zepbound is associated with potential side effects. The most commonly reported side effects include nausea, diarrhea, vomiting, constipation, and abdominal discomfort. Injection site reactions, fatigue, hypersensitivity reactions, burping, hair loss, and gastroesophageal reflux disease are also possible side effects.

? Conclusion

Zepbound is a type of drug that doctors primarily prescribe as a weight loss medication. Medicare does not provide coverage for Zepbound for weight loss or weight management.

However, Medicare does provide coverage for Zepbound when a Medicare-approved doctor prescribes it for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity, to be used in combination with a reduced-calorie diet and increased physical activity.

Sources

• FDA Approves First Medication for Obstructive Sleep Apnea – FDA
• What is Zepbound | Obesity & Excess Weight –  Zepbound® (tirzepatide)