Three Ways Sleep Apnea Patients Can Lower Zepbound® Costs

Liz Paul worked with her doctor and was able to cut her out-of-pocket cost for Zepbound to about $60 for a year. Photo: Courtesy of Liz Paul

If you're a sleep apnea patient struggling with the high cost of Zepbound®, you're not alone.

Liz Paul, a board member for the Obesity Action Coalition, was diagnosed with obstructive sleep apnea (OSA) 15 years ago. She has used CPAP therapy faithfully since then but, with OSA that she calls “pretty severe,” Paul still struggled with the condition.

Zepbound (tirzepatide) is the first medication approved by the FDA specifically to treat moderate to severe OSA linked to obesity. But it comes with a hefty price tag—around $1,000 a month when it isn’t covered by insurance.

Paul found that working with her doctor to explore options allowed her to navigate that barrier—and knock her out-of-pocket cost for Zepbound down to about $60 a month.

“I actually had been trying to access Zepbound for weight but had not had luck, because my insurance wouldn’t cover it for weight,” Paul said. “When it was approved for obstructive sleep apnea, my doctor and I said, ‘This is a good thing to try.’ I do have pretty severe sleep apnea; I can still snore in my mask. Losing weight would be something that should help my sleep apnea, so we put in for the prescription for OSA, but I was denied.

“But it was a strange denial,” she added, “because they wouldn’t even take a prior authorization for my doctor, which she thought was really odd.”

Paul’s insurer later told her they couldn’t accept a prior authorization because they had set their formulary before the Food and Drug Administration (FDA) approved Zepbound for OSA.

Ultimately, Paul’s doctor filed an appeal, requesting an exception based on the FDA’s new approval for OSA patients with obesity. Result: Paul’s insurer approved her coverage for Zepbound for a year, dropping her annual out-of-pocket expense from about $12,000 to $720.

“The biggest thing I learned is that it might not be as simple as my doctor saying, ‘You have OSA and now you can go get this medication,’ because your insurance company may have made their decisions before the FDA approval,” Paul said. “You might have to fight a little bit harder for it.”

This article is based on Paul’s personal experience as a sleep apnea patient and is provided for informational purposes. It should not be taken as medical or financial advice.

1. Check Your Insurance and Medicare Options—and File an Appeal for Denial.

Insurance coverage for Zepbound can vary significantly, so begin by confirming whether or not your plan will cover Zepbound specifically for OSA.

If your doctor’s prior authorization is denied, Paul advises acting quickly to initiate an appeal. She estimated that her appeal took two to three weeks.

2. Explore Manufacturer Savings Programs.

Zepbound's manufacturer also offers savings cards that can significantly reduce the cost for patients who can’t access the medication through insurance. Enrolling in the LillyDirect  program is straightforward through Eli Lilly’s website or with your doctor's help.

The cost varies by Zepbound vial size, ranging from $349/month for a 2.5 mg vial starting dose to $499/month for 5 mg, 7.5 mg, or 10 mg vials. Some conditions and taxes may apply, so visit the program webpage for full details.

Some eligible and commercially insured patients also can take advantage of a $25/month savings card through LillyDirect. Learn more here.

“Even if you do the LillyDirect option that’s $500 a month, that is way better and is certainly something people can look into,” Paul said.

3. Discuss Alternative Treatment Options With Your Doctor

Combining treatments like CPAP therapy with Zepbound could offer both health and cost benefits. So it’s important to discuss with your doctor what therapy or combination of therapies might work best for you—the personalized “right treatment for the right patient” approach that the Alliance of Sleep Apnea Partners champions to help patients achieve their best outcome.

“I'm not looking for Zepbound to cure me of needing my CPAP,” Paul said. “I don’t think that will work for me, at least not in the short term. I think there are complementary things that can work in tandem to improve your sleep and improve your health.”

Tips for Starting the Conversation With Your Doctor

If you think you might be a candidate for Zepbound but are concerned about the cost, these steps can help prepare you to discuss it with your doctor:

• Clarify your insurance or Medicare coverage for Zepbound, as well as a potential appeals process if a prior authorization is denied.

• Discuss all available OSA treatment options and which therapy or combination of therapies might be most effective for you.

• List specific questions about reducing Zepbound costs.

• Request details on available savings programs and alternatives.

“And remember that the drug doesn’t work for everyone,” Paul reminded. “That doesn’t necessarily mean you failed, it’s just a function of the fact that drugs don’t always work for everyone, and not everyone is a super-responder to a medicine. It might not be the same for everyone.”

Even after weight loss, it’s important to have your AHI levels checked, stay on CPAP, and work with your doctor to determine the right treatment approach to manage your OSA moving forward.

Taking control of your sleep apnea treatment costs doesn't have to be overwhelming. Using manufacturer programs, checking insurance coverage, and discussing combined treatment options with your doctor can significantly reduce your financial stress.

As Liz found, advocacy and informed discussions with your healthcare provider can make a big difference.

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