The analysis released by health policy research organization KFF indicates that more than 3 million Medicare beneficiaries could be eligible for coverage of Wegovy, a newly approved weight loss drug that also promotes heart health. However, despite this eligibility, some beneficiaries may still face out-of-pocket costs for the drug, and certain Medicare prescription drug plans may delay coverage until 2025.
The potential coverage of Wegovy by Medicare prescription drug plans could lead to a significant strain on the program’s budget. An estimated 360,000 people, representing just 10% of the eligible population, could result in an additional net cost of $2.8 billion if they use the drug for a full year. This poses a financial challenge for Medicare as more plans consider covering the costs of Wegovy.
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 drug to reduce the risk of heart attacks and strokes. This approval by the Food and Drug Administration opens up access to Wegovy for a sizable portion of Medicare beneficiaries.
Despite potential coverage, Medicare beneficiaries who take Wegovy may still encounter monthly out-of-pocket costs ranging from $325 to $430. The imposition of a new Part D cap on out-of-pocket spending aims to limit these costs to around $3,300 in 2024 and $2,000 in 2025. Nonetheless, these sums remain a financial burden for individuals with modest incomes.
Access Challenges
In addition to out-of-pocket costs, Medicare beneficiaries may face challenges in accessing Wegovy if Part D plans impose certain requirements to control costs and ensure appropriate usage. Measures like “step therapy,” which involves trying other lower-cost medications before using Wegovy, could limit access to the drug for some beneficiaries. This could potentially deter its use among the target population.
While some Part D plans have announced coverage of Wegovy, the extent of this coverage remains uncertain. Many plans may be hesitant to expand coverage due to the inability to adjust premiums mid-year to accommodate the higher costs associated with the drug’s use. As a result, broader coverage of Wegovy by Medicare prescription drug plans may be more likely in 2025.
Medicare already covers GLP-1s and other diabetes treatments, including Novo Nordisk’s Ozempic, for beneficiaries with diabetes who are obese or overweight and have a history of heart disease. These existing coverage options provide some insight into the potential challenges and opportunities associated with expanding coverage to include Wegovy for weight loss and heart health benefits.
While the approval of Wegovy for Medicare coverage presents an opportunity for beneficiaries to access a groundbreaking weight loss drug, challenges related to out-of-pocket costs, coverage limitations, and access barriers must be carefully navigated. Ensuring equitable access to Wegovy for eligible Medicare patients requires a holistic approach that considers both financial implications and healthcare outcomes.
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