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Rachel V Thomas

US Medicare Set To Cover GLP-1 Drugs For Weight Loss: All You Should Know About Eligibility, Costs

For the first time, starting July 1, people in the US will be able to access GLP-1 drugs for weight loss through a new pilot program offered by the federal health insurance program Medicare.

Until now, Medicare covered GLP-1 medications such as Ozempic only for certain conditions like diabetes, but not for weight loss.

The new 18-month Medicare GLP-1 Bridge Program, which will run till the end of 2027, aims to make these high-cost weight-loss medications more accessible to eligible beneficiaries.

According to a KFF analysis of 2023 Part D enrollment data, an estimated 3.8 million Medicare beneficiaries could qualify for the program.

More than 70 per cent of adults in the United States are considered to have obesity or screen as overweight. Studies have proven that GLP-1s are an effective tool in weight reduction, as well as improving other markers of good health, such as blood pressure, lipid profiles, and blood sugar levels.

Eligible beneficiaries will be able to access the following GLP-1 weight-loss medications:

<ul><li>Novo Nordisk's Wegovy injections and tablets</li><li>Eli Lilly's Foundayo tablets</li><li>Eli Lilly's Zepbound KwikPen</li></ul>

The medications will be covered only when prescribed for weight management and when beneficiaries meet the program's medical eligibility criteria.

The program is available only to certain members of Medicare Part D prescription drug plans who want to lose excess weight and maintain weight loss.

Although the program operates outside standard Medicare Part D coverage, beneficiaries can participate only if they are enrolled in:

<ul><li>An eligible stand-alone Medicare Part D prescription drug plan under Original Medicare, or</li><li>An eligible Medicare Advantage plan that includes prescription drug coverage.</li></ul>

People enrolled in certain less common Medicare plans, including the Program of All-inclusive Care for the Elderly (PACE), may also qualify if they also have a stand-alone Part D plan, Washington Post reported.

According to the Centers for Medicare &amp; Medicaid Services (CMS), most of Medicare's approximately 57 million Part D enrollees are in eligible plans.

However, coverage is not automatic. Providers and pharmacists will identify eligible patients, submit the required forms and obtain prior authorization before treatment can begin. Claims, prior authorization requests and pharmacy payments will be handled by Humana, while Part D plans will not be involved in the process.

Eligible beneficiaries will pay a $50 monthly copay for the covered medications.

However, because the program operates outside Medicare Part D coverage:

<ul><li>The $50 copay will not count toward a beneficiary's Part D deductible.</li><li>It also will not count toward the 2026 Part D annual out-of-pocket spending cap of $2,100.</li><li>The copay is not eligible for the Medicare Prescription Payment Plan, which allows beneficiaries to spread prescription drug costs throughout the year.</li></ul>

The pilot program is temporary and is scheduled to end in December 2027, unless it is extended.

"It's certainly good news for Medicare beneficiaries who have been essentially shut out of the market for GLP-1s for weight loss if they wanted to use insurance coverage. However, it is a temporary program. It is not a permanent change in Medicare coverage," said Juliette Cubanski, Vice President and Director of Medicare Policy at KFF.

If the program is not extended, beneficiaries who rely on the medications may have to pay higher out-of-pocket prices or discontinue treatment beginning in January 2028, which experts said could lead to weight regain based on current GLP-1 therapies, the Post reported.

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Ozempic

GLP 1

Foundayo

Medicare GLP 1 Bridge Program

Wegovy

Zepbound

US Medicare

humana

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For the first time, starting July 1, people in the US will be able to access GLP-1 drugs for weight loss through a new pilot program offered by the federal health insurance program Medicare.Until now, Medicare covered GLP-1 medications such as Ozempic only for certain conditions like diabetes, but not for weight loss.The new 18-month Medicare GLP-1 Bridge Program, which will run till the end of 2027, aims to make these high-cost weight-loss medications more accessible to eligible beneficiaries. According to a KFF analysis of 2023 Part D enrollment data, an estimated 3.8 million Medicare beneficiaries could qualify for the program.More than 70 per cent of adults in the United States are considered to have obesity or screen as overweight. Studies have proven that GLP-1s are an effective tool in weight reduction, as well as improving other markers of good health, such as blood pressure, lipid profiles, and blood sugar levels.What Drugs Will Be Covered?Eligible beneficiaries will be able to access the following GLP-1 weight-loss medications:Novo Nordisk's Wegovy injections and tabletsEli Lilly's Foundayo tabletsEli Lilly's Zepbound KwikPenThe medications will be covered only when prescribed for weight management and when beneficiaries meet the program's medical eligibility criteria.Who Will Be Eligible?The program is available only to certain members of Medicare Part D prescription drug plans who want to lose excess weight and maintain weight loss.Although the program operates outside standard Medicare Part D coverage, beneficiaries can participate only if they are enrolled in:An eligible stand-alone Medicare Part D prescription drug plan under Original Medicare, orAn eligible Medicare Advantage plan that includes prescription drug coverage.People enrolled in certain less common Medicare plans, including the Program of All-inclusive Care for the Elderly (PACE), may also qualify if they also have a stand-alone Part D plan, Washington Post reported.According to the Centers for Medicare & Medicaid Services (CMS), most of Medicare's approximately 57 million Part D enrollees are in eligible plans.However, coverage is not automatic. Providers and pharmacists will identify eligible patients, submit the required forms and obtain prior authorization before treatment can begin. Claims, prior authorization requests and pharmacy payments will be handled by Humana, while Part D plans will not be involved in the process.How Much Will It Cost?Eligible beneficiaries will pay a $50 monthly copay for the covered medications.However, because the program operates outside Medicare Part D coverage:The $50 copay will not count toward a beneficiary's Part D deductible.It also will not count toward the 2026 Part D annual out-of-pocket spending cap of $2,100.The copay is not eligible for the Medicare Prescription Payment Plan, which allows beneficiaries to spread prescription drug costs throughout the year.What Happens After 2027?The pilot program is temporary and is scheduled to end in December 2027, unless it is extended."It's certainly good news for Medicare beneficiaries who have been essentially shut out of the market for GLP-1s for weight loss if they wanted to use insurance coverage. However, it is a temporary program. It is not a permanent change in Medicare coverage," said Juliette Cubanski, Vice President and Director of Medicare Policy at KFF.If the program is not extended, beneficiaries who rely on the medications may have to pay higher out-of-pocket prices or discontinue treatment beginning in January 2028, which experts said could lead to weight regain based on current GLP-1 therapies, the Post reported.

us medicare set to cover glp-1 drugs for weight loss: all you should know about eligibility, costs

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US Medicare Set To Cover GLP-1 Drugs For Weight Loss: All You Should Know About Eligibility, Costs

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