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Does Medicare Cover Zepbound for Sleep Apnea?
- Zepbound is the first and only FDA-approved medication for moderate to severe obstructive sleep apnea (OSA), though it should be used in combination with a reduced-calorie diet and increased physical activity.
- Medicare Part D may cover Zepbound if you have an OSA diagnosis and a body mass index (BMI) of 27 or higher. You may be required to get prior authorization or fulfill other eligibility requirements.
- Cost can vary depending on what your Part D plan covers.
Zepbound is the first drug approved by the Food and Drug Administration (FDA) to treat obstructive sleep apnea (OSA) . This weight-loss drug contains the active ingredient tirzepatide. An estimated 100,000 people per month buy Zepbound from Eli Lily’s website, with many paying the out-of-pocket cost, which starts at $249 per fill.
People with Medicare plans may not need to pay full-price for Zepbound if they have a sleep apnea diagnosis. We’ll explain who can get coverage, what kind of Medicare plan you’ll need, and how much a Zepbound prescription will cost.
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How Does Zepbound Work for Sleep Apnea?
Two of the major contributing factors to sleep apnea are neck circumference and weight. When a person has significant weight pressing against their breathing passages, it can cause them to stop breathing while they sleep. Zepbound for sleep apnea is a weight-loss drug that works as an appetite suppressant. By eating less and losing weight, people taking Zepbound have smaller necks, lower body fat, and less pressure on their breathing passages.
Does Medicare Cover Zepbound?
Medicare Part D may cover Zepbound for people with an OSA diagnosis. Medicare Part D is an optional addition to Medicare that covers some name-brand prescription medications . Certain Medicare Advantage Plans (also called Medicare Part C) may also qualify for Zepbound for sleep apnea if their bundled plan includes Part D prescription drug coverage.
Medicare doesn’t cover Zepbound for central sleep apnea (CSA). It also doesn’t cover Zepbound or any other GLP-1 for weight loss. Since Zepbound has been FDA-approved to exclusively treat obesity and sleep apnea, Medicare doesn’t cover Zepbound for diabetes or cardiovascular disease. However, there was a proposed change to Medicare for 2026 to offer wider coverage of anti-obesity medications like Zepbound, but this change hasn’t been implemented .
How Do You Get Medicare to Cover Zepbound for Sleep Apnea?
To qualify for Medicare coverage of Zepbound, you must first receive a diagnosis of obstructive sleep apnea from a doctor. Coverage also requires a body mass index (BMI) of 27 or higher, along with participation in a reduced-calorie diet and increased physical activity. In addition, you must be enrolled in a Medicare Part D plan that covers brand-name prescription drugs or a Medicare Advantage plan that includes Part D coverage.
If you suspect that you have sleep apnea, you can start with contacting their doctor who may order with a sleep study. Following your sleep test, a physician will analyze your results. Depending on the data, they may diagnose you with sleep apnea and provide a treatment plan.
What Medicare Plans Cover Zepbound?
Medicare Part D and Medicare Part C may cover Zepbound when it’s prescribed to treat sleep apnea. Medicare Part D is an optional addition to an existing Medicare plan that helps cover brand-name drugs like Zepbound.
Medicare Part C, also called Medicare Advantage, is a bundled plan offered through Medicare-approved private insurers . Medicare Advantage plans generally include Part A and Part B coverage, and many have Part D coverage as well. If a Medicare Advantage bundled plan includes Part D drug coverage, you may be able to get help paying for Zepbound for sleep apnea.
What Are Medicare’s Requirements for Zepbound Coverage?
To get Zepbound coverage through Medicare, you must have a moderate to severe obstructive sleep apnea diagnosis and a BMI of 27 or higher. You must also have either Medicare Part D drug coverage or a Part C (Medicare Advantage) plan that includes Part D coverage. Currently, Medicare doesn’t cover Zepbound for obesity or any conditions other than obstructive sleep apnea.
How Much Does Zepbound Cost With Medicare?
Zepbound costs depend on your Medicare Part D plan’s formulary. A formulary is the list of drugs that a plan covers, sorted into tiers with different associated prices. Your Zepbound cost depends on which Part D plan you choose and the pharmacy you use. Check your Part D plan and formulary to learn exactly how much Zepbound costs.
How Do You Check if Your Medicare Plan Covers Zepbound?
You can see if your Medicare Part D or Medicare Advantage plan covers Zepbound by checking your plan’s formulary. Typically, you can find the formulary by logging into your member insurance portal or the health plan’s website. You can also speak with your provider’s customer service line and ask if Zepbound is included on your plan’s formulary.
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Cassandra is a health writer who has been a contributor to Sleep Foundation since 2021. She writes about sleep products and reads emerging research to develop science-based articles that help demystify the connection between health and sleep. She's happy to report that she sleeps well most nights, which is probably thanks to her energetic dog and her other work managing a family-owned whitewater rafting business in Upstate New York.
As a board-certified sleep medicine physician with over 20 years of clinical experience, Dr. Adavadkar is an expert in diagnosing and treating sleep disorders in both children and adults, as well as addressing sleep issues experienced by veterans. Dr. Adavadkar is a member of the Sleep Foundation Medical Advisory Board.
References
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FDA Approves First Medication for Obstructive Sleep Apnea. U.S. Food and Drug Administration. Published December 20, 2024. https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea
https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea -
Lupkin, S. “Consumers can buy Zepbound and Wegovy direct from drugmakers if they pay cash.” (March 5, 2025) NPR.
https://www.npr.org/sections/shots-health-news/2025/03/05/nx-s1-5308603/zepbound-eli-lilly-direct-cost -
Medicare.gov (n.d.). What’s Medicare Drug Coverage (Part D)?
https://www.medicare.gov/health-drug-plans/part-d -
Centers for Medicare & Medicaid (November 26, 2024). Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4208-P).
https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription -
U.S. Department of Health & Human Services (July 22, 2024). What is Medicare Part C?
https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html
