An injection pen of Zepbound, Eli Lilly’s weight reduction drug, is displayed in Fresh York Town on Dec. 11, 2023.
Brendan McDermid | Reuters
Medicare drug plans can now barricade Eli Lilly‘s blockbuster weight problems drug Zepbound for obstructive sleep apnea, CNBC showed on Wednesday.
That opens the door for broader get right of entry to to Zepbound, which isn’t these days coated by means of Medicare and lots of alternative insurance policy for weight reduction. Call for for the injection has soared over the closing while regardless of its more or less $1,000 per month price tag ahead of insurance coverage.
In a commentary to CNBC, a spokesperson for the Facilities for Medicare & Medicaid Services and products, an company of the U.S. Segment of Fitness and Human Services and products, mentioned “current Medicare Part D and Medicaid coverage rules apply” to Zepbound following its landmark approval in December for essentially the most ordinary sleep-related respiring defect.
Medicare Phase D plans can simplest barricade weight problems medication if they’re impaired for an additional medically accepted purpose licensed by means of the Meals and Drug Management, the CMS spokesperson mentioned, regarding the company’s guidance. The spokesperson added that Phase D plans might believe the usage of prior authorization — a procedure the place a supplier should first get kindness from an insurer — for the ones medication to assure they’re being impaired for that exact function.
The FDA on Dec. 20 cleared Zepbound for sufferers with weight problems and moderate-to-severe methods of obstructive drowse apnea, or OSA, which refers to respiring interrupted all the way through drowse because of narrowed or prevented airlines. That made Zepbound the primary drug remedy cleared for the estimated 20 million population with the ones methods of the defect, consistent with Eli Lilly.
In a commentary on Thursday, Eli Lilly referred to as Medicare’s protection of Zepbound for the status “good news.”
Medicare Phase D plans are in a similar way allowed to barricade Novo Nordisk‘s weight reduction drug Wegovy for its other approved use: decreasing cardiovascular dangers. The diabetes opposite numbers of Wegovy and Zepbound — Ozempic and Mounjaro, respectively — are coated by means of Medicare and maximum insurance policy.
Each Novo Nordisk and Eli Lilly are finding out their weight reduction drugs as remedies for fatty liver defect, persistent kidney defect, drowse apnea and extra. To be coated, the ones medication would wish to go back late-stage trial effects and nearest be submitted for FDA kindness for the ones makes use of.
In the meantime, situation Medicaid protection for Zepbound and alternative weight problems healings is dependent upon what status they’re prescribed for and whether or not their producer has signed a definite Medicaid drug rebate agreement, consistent with the spokesperson.
Underneath that oath with the secretary of Fitness and Human Services and products, producers conform to handover rebates to states in alternate for Medicaid protection in their medication. States percentage the rebates with the government.
A situation Medicaid program should barricade Zepbound whether it is prescribed for OSA and Eli Lilly has signed the Medicaid drug rebate oath, the spokesperson mentioned.
But when Zepbound is prescribed for weight reduction, situation Medicaid systems aren’t required to barricade it.
The Biden management in November proposed a rule that will permit Medicare and Medicaid to barricade weight reduction medication for sufferers with weight problems. The guideline would give tens of millions of population get right of entry to to weekly injectables, however it will value taxpayers up to $35 billion over the nearest decade.
It’s opaque if President-elect Donald Trump’s management will pursue the rule of thumb.
