Starting tomorrow, July 1, millions of people with Medicare drug coverage could qualify for lower-cost weight loss medications including Wegovy and Zepbound.
GLP-1 treatments have surged in popularity in recent years, but their high cost has kept them out of reach for many patients who may benefit from them.
One of the biggest barriers has been the monthly price. CNN previously reported that Wegovy and Zepbound had, at one point, been listed at around $1,000 per month.
That is now set to shift for some eligible patients through a temporary initiative known as Medicare GLP-1 Bridge, which could reduce the cost of these medications to as little as $50 a month.
The short-term program is available nationwide and applies to certain Medicare Part D beneficiaries. In addition to standalone prescription drug plans, it can also apply to many Medicare Advantage plans with drug coverage, certain Special Needs Plans, employer or union group waiver plans, and the Limited Income Newly Eligible Transition program.
To qualify, people must be 18 or older and enrolled in Medicare drug coverage, and they must meet specific health requirements. The program is not for people who are already getting GLP-1 drugs covered through their Medicare drug plan.
According to the Medicare website, eligibility depends in part on BMI. Anyone with a BMI of 35 or more may qualify. Those with a BMI between 30 and 34.99 must also have at least one of the following conditions: diastolic heart failure, uncontrolled high blood pressure, chronic kidney disease at stage 3a or higher, prediabetes, a previous heart attack or stroke, or blocked arteries in the legs or arms with symptoms.
For people with a BMI between 27 and 29.99, they must also have prediabetes, a previous heart attack or stroke, or blocked arteries in the legs or arms with symptoms.
People who take GLP-1 drugs for type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease are not eligible for the bridge program, because those uses are still expected to be covered through Medicare Part D instead.
Those who are accepted into the program will pay $50 per month for the medication. The $50 copay will not count toward the Part D deductible or out-of-pocket maximum, and low-income subsidies will not apply to prescriptions filled through the bridge.
Anyone seeking access through the new scheme will need to visit their doctor. The doctor must send a prescription for the GLP-1 medication to the patient’s pharmacy and complete prior authorization if it is requested.
The Centers for Medicare & Medicaid Services states: “Your provider must certify that you’re using the GLP-1 drug as part of a lifestyle program that focuses on diet and exercise.”
If approved, the coverage will remain in place until December 31, 2027.
The medications included in the program are Foundayo, Wegovy injections and tablets, and Zepbound KwikPen. Only the KwikPen version of Zepbound is included in the bridge, not the single-dose vial or single-dose pen formulations.
Federal rules normally prevent the government from paying for GLP-1 medications when they are prescribed only for weight loss under Section 1927(d)(2) of the Social Security Act.
The Social Security website says some medications can be excluded or face Medicare limits, including drugs that are “used for anorexia, weight loss, or weight gain”.
Even so, the administration is permitted to operate a temporary demonstration project to test different approaches to payment and coverage, which is how Medicare GLP-1 Bridge can move forward.
Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for more information about Medicare GLP-1 Bridge.