Beginning this July, Medicare will cover Wegovy and Zepbound for people over 65 who want to lose weight under the pilot GLP-1 bridge program. Medicare’s coverage is temporary and circumvents federal law, reports Bob Herman for StatNews. It will generate billions of dollars for Eli Lilly and Novo Nordisk, which manufacture these two drugs, and could cost taxpayers as much as $30 billion a year if everyone eligible enrolls in the program.
To date, Medicare has only covered GLP-1 drugs for the 16 million people with Medicare who have diabetes, cardiovascular issues, and sleep apnea. This new pilot program extends coverage of Wegovy and Zepbound to another 13 million people with Medicare who are obese.
The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, intended for Part D insurers and Medicare Advantage plans to participate in this pilot program, but they refused to, concerned about its potentially high cost. So, instead, taxpayers are covering the cost of this program, along with the people who enroll in it.
CMS, for its part, has refused to release information on the cost of this pilot program. What we do know is that Medicare’s monthly cost for Wegovy and Zepbound is $245. Individuals will pay $50 a month, and the cost to taxpayers will be $195 a month for each person who participates in the pilot. People’s copay will not count toward their Part D $2,100 out-of-pocket cap.
It is reasonable to assume that coverage of these drugs through this pilot could increase Medicare Part B premiums significantly. Even if only one in three eligible individuals participate in the pilot, it will cost $10 billion.
Under federal law, Medicare cannot cover drugs for weight loss. The Trump administration is using special powers conferred to CMS under the law to test new Medicare payment models through the Center for Medicare and Medicaid Innovation (CMMI). That said, CMMI is only legally allowed to test budget-neutral models, ones that do not cost taxpayers more.
Here’s more from Just Care:
- Daily GLP-1 pill could work as well as Ozempic
- The possible anti-cancer benefits of Ozempic and other GLP-1 drugs
- Poll: More than 10 million people with Medicare very worried about affording their drugs
- Whether you’re taking a weight-loss drug or not, you’re paying for it
- Medicare’s new negotiated drug prices are lower but some are still twice as high as Canada’s
