For the first time, Medicare will cover GLP-1s for obesity-related weight loss without any other medical conditions, dramatically expanding access for millions of seniors.
Starting Wednesday, eligible Medicare beneficiaries can receive GLP-1s for obesity for $50 per month by prescription. Medicare is the primary federal health insurance program in the U.S. for individuals 65 and older.
Federal rules ban Medicare Part D from covering drugs solely to treat obesity, but a new federal pilot bridge program approved by Health and Human Services Secretary Robert F. Kennedy Jr. will be in effect until Dec. 31, 2027.
The program will cover Eli Lilly’s Foundayo and Zepbound and Novo Nordisk’s Wegovy for seniors 65 and older, as well as other eligible Medicare enrollees.
How It Works
The government negotiated with manufacturers to reduce the price the government will pay to $250 for a month’s supply. In return, the companies will have access to the larger patient population. Each patient will pay a $50 copay toward the cost of the medication, but that copay will not go toward an individual’s annual deductible.
Patients will first need prior authorization — prescribing clinicians will submit documentation proving the patient meets strict body mass index and health condition requirements. That means patients will need to wait for the prescription to be approved before it can be filled.
Eligibility Requirements
Patients must have a Body Mass Index of 35 or higher. If their BMI is 30-35, they must have certain types of heart failure, hard-to-control blood pressure, or chronic kidney disease.
If their BMI is 27-30, they must have prediabetes, a history of heart attack or stroke, or blocked arteries in the arms or legs.
These requirements are more restrictive than the FDA approval language or what private insurance companies require, which is a BMI of 30 or over.
Patients must also not have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease because their Medicare plan may already cover GLP-1s for those conditions.
Access and Availability
A month’s supply of Wegovy will come in four pre-filled pens, while Zepbound will be delivered in a KwikPen, which holds four weekly doses in a single device. Foundayo and Wegovy Pill are daily tablets. Wegovy and Zepbound are weekly injections that require refrigeration.
Single-dose Zepbound pens and Zepbound vials will not be covered by the bridge program.
Individuals will be able to fill their pre-approved prescriptions at local retail pharmacies and directly through Novo Nordisk or Eli Lilly’s direct-to-consumer mail-order pharmacies.
The Impact
An estimated 3.8 million beneficiaries could be eligible for the program, according to a KFF analysis of 2023 Part D enrollment data.
“These treatments are a major medical advancement, but too many seniors are currently unable to access them due to high cost,” Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid, said in a statement. “The Medicare GLP-1 Bridge changes that by making these medications more affordable and accessible.”
The Bottom Line
A new Medicare bridge program in the United States will allow eligible seniors to access GLP-1 weight-loss drugs for $50 a month starting July 1. The program covers Eli Lilly’s Foundayo and Zepbound and Novo Nordisk’s Wegovy. Patients must meet strict BMI and health requirements, including a BMI of 35 or higher or lower BMIs with certain conditions. The program is set to run through Dec. 31, 2027.
