Millions of Americans on Medicare are slated to gain cheaper access to GLP-1 weight loss drugs for the first time this week – as the government will soon foot most of the bill.
The pills and injectables will be covered by the government health insurance program starting Wednesday under a temporary pilot program known as the “Medicare GLP-1 Bridge.”
Eligible patients will be required to pay $50 a month for popular Novo Nordisk and Eli Lilly medications, such as Zepbound and Wegovy.
The shots and pills, which can help people lose dozens of pounds in just a few months, typically cost hundreds of dollars a month even with insurance. The pricing has been a barrier to access that companies are trying to address.
“These treatments are a major medical advancement, but too many seniors are currently unable to access them due to high cost,” Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz said when he announced the plan last month.
Who Is Eligible?
Medicare serves patients aged 65 and older and younger people with disabilities.
There are 56 million people who are enrolled in Medicare Part D, according to an analysis from the non-profit health research group KFF.
The people eligible for the pilot program are in Part D prescription drug plans. That’s over half of Part D enrollees.
Only people whose health is at risk because of obesity get access, although some people who have prediabetes, are overweight or have a history of heart problems may also qualify, according to the Centers for Medicare & Medicaid Services.
People who already have GLP-1 drugs covered through their Medicare Part D plan or have Type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease are not eligible.
What Drugs Are Available?
There are three drugs that people will be allowed to obtain through the pilot program, according to Oz.
Those include the shots Zepbound and Wegovy – made by Eli Lilly and Novo Nordisk, respectively – and Foundayo, Eli Lilly’s answer to the Wegovy pill.
The pills offer a less invasive option for people who are a little needle shy and can be similarly in impact.
Still, Zepbound is considered one of the most powerful options, leading to an average weight reduction of nearly 21 percent body weight after 72 weeks.
How Do You Get Them?
The pilot program is operating in every state and territory.
If you qualify for the program, your doctor will send a prescription for the GLP-1 drug to your pharmacy and complete a prior authorization when requested.
“Your provider must certify that you’re using the GLP-1 drug as part of a lifestyle program that focuses on diet and exercise,” the Centers for Medicare & Medicaid Services says.
Prior authorization is a health insurance requirement where your doctor must get approval from your plan before covering a specific drug, according to the National Association of Insurance Commissioners.
Once approved, the coverage will be valid through December 31, 2027, unless patients change GLP-1s. It’s unclear what will happen to the program if that occurs.
Why Temporary?
Federal law prohibits Medicare from covering these drugs. That’s why the Trump administration is doing it under its authority to run a temporary “demonstration” project to test new payment and coverage.
“When it expires, it is unclear how beneficiaries will access GLP-1 medications at an affordable price,” Stacie Dusetzina, a health policy professor at Vanderbilt University, wrote in a recent article in The New England Journal of Medicine. That raises the prospect, she said, that patients will stop taking the drugs and regain weight, which will lead to “poor clinical outcomes.”
