A recent analysis conducted by health policy research organization KFF has found that over 3 million Medicare patients may be eligible for coverage of the weight loss drug Wegovy. This comes after the drug was approved in the U.S. for its potential benefits in improving heart health. However, despite the eligibility, some beneficiaries may still face out-of-pocket costs for the drug, and certain Medicare prescription drug plans may not cover Wegovy until 2025.
The potential coverage of Wegovy by Medicare could strain the program’s budget, with estimates suggesting that prescription drug plans could spend an additional net $2.8 billion if just 10% of the eligible population uses the drug for a full year. This raises concerns about the financial impact on Medicare.
Under new guidance issued in March, Medicare Part D plans can cover Wegovy for patients who are obese or overweight, have a history of heart disease, and are specifically prescribed the weekly injection to reduce their risk of heart attacks and strokes. This guideline applies to approximately 3.6 million beneficiaries, which accounts for 7% of the total Medicare population.
While this coverage is a positive step forward, KFF’s analysis reveals that Medicare beneficiaries taking Wegovy may still face monthly out-of-pocket costs ranging from $325 to $430. This is due to the requirement of paying a percentage of the drug’s list price for a month’s supply. Although a new Part D cap on out-of-pocket spending will limit costs to around $3,300 in 2024 and $2,000 in 2025, these amounts can still be burdensome for those with modest incomes.
There may also be challenges in accessing Wegovy, as some Part D plans could implement cost-control measures and requirements to ensure appropriate use of the drug. This could include “step therapy,” which necessitates trying other lower-cost medications or weight loss methods before using Wegovy. These factors could potentially hinder the use of Wegovy among Medicare beneficiaries, even within the target population.
While some Part D plans have already announced that they will cover Wegovy this year, it remains uncertain how widespread the coverage will be. Many plans may be hesitant to expand coverage due to the inability to adjust premiums mid-year to account for the higher costs associated with the drug. Therefore, broader coverage is more likely to occur in 2025.
It is worth noting that Medicare already covers other GLP-1 drugs, including Novo Nordisk’s Ozempic, for the treatment of diabetes. Among the Medicare beneficiaries who are obese or overweight and have a history of heart disease, 1.9 million also have diabetes, making them eligible for coverage of other GLP-1 drugs approved for diabetes management.
In conclusion, the analysis conducted by KFF highlights the potential eligibility of over 3 million Medicare patients for coverage of the weight loss drug Wegovy. While this is a positive development for improving heart health, there are concerns regarding out-of-pocket costs and the strain it may put on Medicare’s budget. The implementation of cost-control measures by Part D plans could further complicate access to Wegovy. Nonetheless, with the potential for broader coverage in 2025, there is hope that more beneficiaries will be able to benefit from this medication in the future.
