If you’ve been struggling with obstructive sleep apnea (OSA), you may be wondering if Medicare covers Zepbound for sleep apnea. Recent updates show that Zepbound is the first medication approved by the Food and Drug Administration (FDA) to treat mild to moderate obstructive sleep apnea (OSA) in adults with obesity.
This once-weekly injectable treatment contains the active ingredient tirzepatide, a powerful dual-action GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 (glucagon-like peptide-1) receptor agonist.
After a year of treatment with Zepbound, 42% of adults with obstructive sleep apnea or mild, non-symptomatic OSA had no sleep apnea, compared to 16% with a placebo. However, the cost of Zepbound, at around $1,060 per month without insurance, makes accessibility a challenge for many. Fortunately, Medicare Part D plans can now cover Zepbound when prescribed for OSA.
Read on to learn how Medicare makes Zepbound accessible to millions seeking relief from sleep apnea.
What Is Obstructive Sleep Apnea (OSA)?
Obstructive sleep apnea (OSA) is a common sleep disorder that occurs when the upper airway becomes partially or completely blocked during sleep. This blockage disrupts normal breathing, leading to repeated pauses in airflow that can last from a few seconds to a minute.
When someone has obstructive sleep apnea (OSA), their breathing may stop hundreds of times during the night. Apneas refer to these breathing pauses. The absence of airflow for ten seconds or more is called an obstructive apnea episode.
Common symptoms of sleep apnea include snoring, difficulty sleeping, and excessive daytime sleepiness. OSA can affect anyone, but certain factors increase the likelihood of developing the condition, including:
- Obesity, or being overweight.
- A family history of sleep apnea.
- Anatomical factors such as a narrow airway or large tonsils.
- Smoking or alcohol consumption.
Overweight and obesity are major risk factors for OSA, particularly when the distribution of fat increases the circumference of the neck; it can also increase the risk of sleep apnea when fat deposits fill the throat or increase the size of the tongue; even a little weight gain can increase the risk of sleep apnea in children and adults.
Left untreated, OSA can lead to serious health issues, including high blood pressure, heart disease, stroke, type 2 diabetes, or even death. The persistent lack of restorative sleep can also impact an individual’s quality of life and overall well-being.
Does Medicare Cover Zepbound for Sleep Apnea?
Medicare Part D plans can now cover Zepbound when prescribed for obstructive sleep apnea (OSA). This change follows the FDA’s recent approval of Zepbound as the first prescription medication to treat mild to moderate OSA in adults with obesity.
Zepbound now joins Novo Nordisk’s Wegovy in gaining Medicare coverage. Wegovy, which has the same active component as Ozempic, qualified after its use was extended to include lowering cardiac risk in people with obesity or overweight.
Medicare generally does not cover Zepbound and other GLP-1 receptor agonists prescribed solely for weight loss unless approved for secondary use by the FDA. In other words, if you want to use Zepbound for weight loss only, it will not be covered by Medicare, and you will have to pay for it out of pocket.
Zepbound is only covered if you have Medicare Part D, which covers prescription drugs. However, Zepbound is not covered by Medicare Part B. Medicare Part B only covers diabetic medical supplies, specific drugs and vaccines, and some doctor-administered therapies.
If you have a Medicare Advantage or “Part C” plan, check to see if Zepbound is now covered. While these plans may cover prescription medicine, the costs and drugs covered can vary. Your health insurance may also require prior authorization before covering Zepbound. To know if your plan covers Zepbound, check your plan’s formulary or list of approved medications, which determines your options for prescription drug coverage.
Medicare Coverage Criteria for Zepbound
To be eligible for Zepbound Medicare coverage, you may have to meet certain requirements. These requirements may vary depending on your specific Medicare plan and the guidelines established by the Centers for Medicare and Medicaid Services (CMS). The following are some common criteria that you may need to meet:
- Medicare Part D enrollment: You must be enrolled in a Medicare Part D plan, as Zepbound is classified as a prescription drug under this program. Those without Part D coverage will not qualify for Medicare assistance with the medication.
- Medical necessity: Your prescribing healthcare provider must document that Zepbound is medically necessary to manage OSA. This includes evidence of the condition, such as diagnostic tests like sleep studies and a history of prior treatments that were ineffective or unsuitable, such as positive airway pressure (PAP) therapy.
- Prior authorization: Many Medicare Part D plans require prior authorization for Zepbound. This step ensures that the medication is being used for its approved purpose. Your provider will need to submit documentation supporting the diagnosis of OSA and the necessity of the treatment.
It’s essential to remember that Medicare’s requirements for Zepbound coverage may vary, so it’s important to speak with your insurance company and healthcare practitioner to find out what your particular requirements are.
Can You Appeal if Medicare Denies Coverage for Zepbound?
You can appeal if Medicare denies coverage for Zepbound prescribed for obstructive sleep apnea (OSA). If your Medicare plan denies coverage for Zepbound, you will receive a notification with the reasons for the denial. You will also be informed on how to appeal the decision. Follow these steps to file an appeal:
1. Review the denial notice: Carefully review this notice to know why Zepbound was not approved and whether you need additional documentation to be approved.
2. Gather your personal ‘ supporting evidence’: Compile as much evidence as you can about OSA. Recent tests, such as your sleep studies, can be helpful. If your plan requires step therapy, include a list of all the drugs you have tried in the past to treat your condition.
Positive airway pressure (PAP) therapy is one of the frequently recommended devices for sleep apnea. Look up the list of recommended treatments in your plan’s formulary. Record the duration and dates you took each treatment, its effectiveness, and any adverse effects you experienced. If you haven’t tried any of them, create a plan with your healthcare provider to explain why step therapy treatments are unsuitable for you in your appeal. If you’ve tried Zepbound before, highlight any positive changes you’ve experienced.
3. Seek assistance: Navigating the appeals process can be complex. You can seek help from your healthcare provider or a professional service like NP2GO to gather supporting documentation and strengthen your case. We can help you provide additional insight and guidance on how to be successful with the appeals process.
4. Submit an appeal: Follow the guidelines in the denial notice to submit your appeal. This could entail sending a letter outlining your reasons for appealing the denial or completing specific forms. Make sure the required supporting evidence accompanies your appeal.
Remember that most insurance companies give a time frame of 30 to 60 days to process an appeal decision. Take note of the date you filed your appeal so you may follow up with your insurance company if you haven’t heard back from them within the given time.
What if My Medicare Plan Does Not Cover Zepbound for Sleep Apnea?
Medicare will not cover Zepbound for weight loss if you have not been diagnosed with sleep apnea. Currently, there’s no approved generic version of Zepbound, and brand-name Zepbund costs around $1,060 per month out of pocket. If Medicare won’t pay for Zepbound, there are still other methods to save money.
1. Compounded tirzepatide
Drug compounding is the process of combining and mixing ingredients to create a medication tailored to an individual patient’s needs. Compounded tirzepatide is a cost-effective alternative to the brand-name Zepbound. Compounding pharmacies can create medications with the same active ingredient, tirzepatide, often at a lower price. At NP2GO, we offer compounded tirzepatide and semaglutide to meet the needs of our patients. Our compounded tirzepatide costs between $200 and $600 per month.
2. Price-shop at different pharmacies
Consider calling several local pharmacies or looking up prices on their websites. Zepbound’s list price is $1,060 for a 28-day supply; however, pharmacies may charge a higher retail price. It’s a good idea to check because certain pharmacies may also have Zepbound at a lower cost than others. You can also buy Zepbound online via our clinic or a mail-order pharmacy. Additionally, if you order Zepbound for two or three months, some pharmacies will give you a discount.
3. Look into pharmacy discount programs
Programs like GoodRx and drugs.com can provide discounts on Zepbound at participating pharmacies. These can reduce the price of Zepbound significantly.
4. Consider Zepbound alternatives
Talk to your healthcare provider about other Zepbound alternatives that might be more affordable. Mounjaro (tirzepatide), for instance, is a once-weekly injectable medication that contains the same active ingredient and dosages as Zepbound. It is FDA-approved to help people with type 2 diabetes manage their blood sugar levels. However, healthcare providers prescribe it off-label for weight loss. And because it’s primarily approved for the treatment of type 2 diabetes, Mounjaro may be covered by Medicare, but only if you are taking it to treat type 2 diabetes.
FAQ About Medicare Covering Zepbound for Sleep Apnea
Get Zepbound Through NP2GO Clinic
If you’ve been diagnosed with obstructive sleep apnea (OSA), the newly expanded Medicare Part D coverage for Zepbound opens new possibilities for treatment. This GLP-1 medication not only helps manage sleep apnea symptoms but also supports healthy weight loss, addressing one of the main causes of OSA.
Understanding Medicare coverage can feel confusing, but you don’t have to navigate it alone. At NP2GO, our licensed providers can help simplify the process by helping you confirm eligibility, handle prior authorizations, and explore affordable alternatives when needed.
We’re committed to helping you achieve better sleep, improved health, and sustainable results through personalized and affordable care. If Zepbound isn’t covered under your current plan, we also offer compounded tirzepatide and semaglutide options that provide similar benefits at a lower cost.
We serve patients in Oklahoma and over 28 states through convenient telehealth visits and in-office care. Book an appointment today to learn whether Zepbound or a compounded alternative is right for you and take the next step toward better rest and overall wellness.