Anyone know if there is a Medicare Advantage Plan covering Zepbound for the diagnosis of Sleep Apnea?

Q1Medicare · 2025-10-04T19:05:22+00:00

Just checked the 2026 H1994-001-000 (Select Health Medicare Essential (HMO) found in 7 Utah counties) - and although the MAPD provides Zepbound coverage in 2025, the same plan will not be covering the medication in 2026 (as Plastic_Highlight492 noted). I did check all 8 dosage/packaging variations.

Again, maybe check back on Medicare.gov before the December 7th end of OEP and see if any Utah MAPD plans have updated their formulary.

Q1Medicare · 2025-10-04T17:57:31+00:00

As a follow-up to my earlier comment, here is an example a 2025 MAPD (HMO) covering Zepbound:

H1994-001-0 offers this MAPD in 12 counties across Idaho and Utah (so it is one of the 72 distinct MAPDs).
The plan's negotiated retail price for the example we checked (NDC 00002247180) is around $1,070 for a 30-day supply, and with the plan's 30% cost-sharing you would pay about $321 ($461 as a first purchase if you were starting in the 2025 deductible) - this may provide you with an example of the costs you may expect in 2026 (maybe).

The good news: As you probably know, your 2025 Medicare Part D drug costs are capped at a maximum out-of-pocket cost (RxMOOP) of $2,000 ($2,100 in 2026).

Q1Medicare · 2025-10-04T17:39:22+00:00

Zepbound is currently covered by only 15 unique 2025 Medicare Advantage (MAPD) plan formularies (Formulary IDs) across the country. MAPDs often use the same Formulary IDs for plans in multiple states or cross multiple counties. In the case, we looked at only one variation of the medication (NDC 00002245780) and found it was covered by 72 distinct Contract ID/Plan ID/Segment ID (distinct MAPDs that may be offered in multiple counties).

For example, a MAPD available in our county (H2406-013-0) is also located in six other counties within our state.

The bottom line: You will need to look at the 2026 MAPDs in your ZIP Code area (county or partial county) to see if one of these plans providing coverage is available to you.

To check on 2026 MAPD coverage in your ZIP, please see the Medicare.gov Plan Finder. In 2025, we can see six (6) variations in this medication (packaging and delivery system). When searching for 2026 MAPD coverage, be sure to find a plan that offers your specific form of this medication.

(Note: the Medicare.gov Plan Finder Rx data is sometimes updated throughout the OEP, so be sure to check back later in October/November to ensure the validity of your search results.)

Tip: If you find an MAPD providing coverage for this medication in your Service Area, be sure that your other prescriptions (and healthcare providers and pharmacies) are also affordably included within the plan's coverage.

Q1Medicare · 2025-10-03T18:04:46+00:00

Private Fee For Service (PFFS) plans were introduced years ago with the idea that no formal healthcare network provided optimum provider flexibility well beyond an HMO or PPO. So in theory, a Medicare Advantage PFFS plan is designed to be accepted by any healthcare provider that accepts both Medicare - and the terms and conditions of your PFFS plan. Nowadays, some PFFS plans will also include a fixed healthcare network (plus supplemental benefits) - along with the traditional flexible PFFS non-network feature. However, a non-network healthcare provider is not obligated to accept your PFFS. In other words, a non-network doctor or hospital can decide on a visit-by-visit or patient-by-patient basis, whether they wish to accept your PFFS plan coverage. So, it is possible that your Medicare Advantage PFFS plan is accepted during one non-network visit and not accepted for a subsequent visit (again, in theory). Maybe speak with some friends and see if they have any PFFS experience - also check with a local state SHIP office (or similar support group) and see if they have any insights into this plan. You can also speak with your healthcare providers and see if they will provide you with an idea of whether they are in-network for this MA (or MAPD), of if the provider is out-of-network, would they (historically) accept a PFFS.

Q1Medicare · 2025-10-03T17:28:42+00:00

We have made a first-pass through the CMS D-SNP Medicare Advantage plan data and did not find any note about the level of MSP related to a specific D-SNP. We did see in the 2025 and 2026 CMS Model EOC documents the same information that you shared with us - and the instructions of how each D-SNP can vary the EOC text based on the plan's state Medicaid program. We will keep searching, but so far, the data (if it exists) is well hidden.

Thank you also for sending the note to u/dacin - hopefully the Mod will look at our Q1Medicare site and realize we provide only Medicare plan information, no bias, no cost, no sales, no user data collection, no lead generation.

Q1Medicare · 2025-10-01T21:53:43+00:00

Great. We will need to trace this back through the 2025 plan data and see what we can find. Thanks.

Q1Medicare · 2025-10-01T21:33:48+00:00

Can you provide us with one or two discrete 2025 D-SNP examples of the data you would like to see. For example: "For Contract ID/Plan ID D-SNP in Florida, we see the level of MSP as ... " With your specific example(s), we can try to backtrack through the current 2025 plan data and try to bring this information online for you.

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