Medicare Insurance Coverage, Zepbound expenses, and additional information
Medicare Part D, prescription drug plans offered by Medicare-approved private insurance companies, may soon see changes in their coverage of the anti-obesity medication Zepbound.
Currently, Medicare does not cover Zepbound and other anti-obesity medications (AOMs) for weight reduction or management due to rules that exclude "agents when used for weight loss." However, Zepbound has been approved by the Food and Drug Administration (FDA) to treat obstructive sleep apnea (OSA) in people with obesity. If a person's doctor prescribes Zepbound for OSA and the drug is in their Part D plan's formulary, they should receive Medicare coverage for it.
The Centers for Medicare & Medicaid Services (CMS) is considering reinterpreting its rules regarding AOMs. Policymakers are exploring whether and how to increase access to these drugs for Medicare members. If Medicare expands Part D coverage to include AOMs, it might extend coverage to an additional 3.4 million enrollees, according to recent estimates.
Approximately 20% of Medicare enrollees have a diagnosis of obesity. If the coverage expansion goes ahead, it could have significant cost implications for the Medicare program. If Medicare expands coverage to AOMs, the cost implications for the Medicare program could be significant.
It's important to note that Part D plans may differ in the drugs that they cover. Each plan has a list of covered drugs called a formulary. The cost of Zepbound with Medicare Part D may vary based on coverage, the plan, the insurer, and a person's location. A person may wish to contact their insurance provider to learn exactly how much Zepbound could cost with their coverage.
If a person has Original Medicare, they can buy a stand-alone Part D plan in addition to their Part A and Part B coverage. If a person has a Medicare Advantage (Part C) plan, they likely have Part D drug coverage bundled with their plan.
Changes to Part D coverage of Zepbound could go into effect in 2026. The US government is planning a five-year pilot program that would allow Medicare and Medicaid to cover GLP-1 medications like Zepbound for weight control. This would open up a significant new market, as Medicare has primarily covered these medications only for diabetes patients so far.
In 2025, Part D plans will have a maximum annual deductible of $590. A person's out-of-pocket costs for covered drugs, including Zepbound, cannot exceed $2,000 in a given year.
These potential changes in Medicare coverage for Zepbound and other AOMs are an important development for the millions of Medicare enrollees who struggle with obesity. As always, it's recommended to consult with a healthcare provider and insurance provider for personalised information and guidance.
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