Does Medicare Cover Zolpidem? 

There’s nothing quite like a good night’s sleep. Sleep restores energy, promotes healing and allows the mind to work through stress, all functions that keep you healthy and ready to tackle challenges each day. Sadly, statistics from the National Institutes of Health show that around half of all American seniors suffer from some degree of insomnia.

Additionally, sleep patterns change with age. Seniors often find themselves awake at night as they get older. Another problem seniors face in terms of sleep is the change in schedule upon reaching retirement. It’s easy to lose track of time and get off a set schedule when you don’t have to report to a job each day. Some retirees find that adjusting to retired life can be difficult without a schedule, and this can lead to sleep difficulties.

How is insomnia treated in seniors?

To tackle insomnia, doctors may recommend lifestyle changes, including changes to diet and exercise. If you smoke or drink alcohol, your doctor will also likely recommend smoking cessation and limiting alcohol or eliminating it from your diet altogether. You may also need to change nighttime behaviors like spending time in front of a computer or smartphone or limiting exposure to television for a few hours prior to going to bed.

Medication to treat insomnia in seniors

If your insomnia doesn’t respond to lifestyle changes, medications like zolpidem may be prescribed. Zolpidem, also available under the brand name Ambien, is a prescription sleep medication that works by affecting gamma-aminobutyric acid (GABA) in the brain. GABA is a neurotransmitter or chemical that relays information. By activating increased GABA, the brain and nervous system slow down, allowing you to fall asleep easier and stay asleep longer.

How does Medicare cover Zolpidem?

Most Medicare benefits plans cover Zolpidem through the prescription drug benefit portion of the program known as Medicare Part D. Part D covers prescription drugs that are available for self-administration at home. Medicare Part D does not cover infused medications administered in a medical facility. It only covers prescription drugs that are picked up at traditional or mail-order retail pharmacies.

Zolpidem must be prescribed as a medical necessity in order to be considered for Medicare coverage. The prescribing physician must also participate in the Medicare program. Part D plans require a monthly premium with some Medicare recipients also paying an additional premium based on income level. You must meet your deductible for the year before Part D benefits will pay for Zolpidem.

When you pick up your prescription from your pharmacy, a copay may be due. This copay is determined by your plan, and you can learn more about copays and coverage limits by checking your Part D formulary. This document lists the medications included in your plan and provides added information about limitations and restrictions on covered drugs.

Other forms of Medicare coverage for Zolpidem

Zolpidem may also be covered by the inpatient benefits of Medicare known as Medicare Part A. If you are given Zolpidem while admitted to a Medicare-participating hospital or skilled nursing facility, Medicare covers the cost during your stay under Medicare Part A. As a part of Original Medicare, Part A covers all inpatient care, including administered prescriptions, for a total of 60 days per benefit period.

If you are administered Zolpidem in an outpatient setting, such as when you have a sleep study conducted, Medicare Part B applies. Medicare Part B is the other part of Original Medicare and covers 80% of outpatient costs, including medications provided in an outpatient setting. There is a monthly premium required to carry Medicare Part B as well as a deductible to meet before benefits apply toward care.

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