More than 3 million people with Medicare could be eligible for Wegovy coverage now that the hit weight-loss drug is also approved in the U.S. for heart health, according to an analysis released Wednesday by the organization. KFF health policy research.
But some eligible beneficiaries could still face out-of-pocket costs for the highly popular and expensive drug, KFF said. TRUE Medicare prescription drug plans can also wait until 2025 to cover Wegovy.
Medicare's budget could take a hit as more plans cover Wegovy costs. The program's prescription drug plans could spend an additional net $2.8 billion if just 10% of the eligible population, about 360,000 people, used the drug for a full year, according to KFF.
Under new guidelines released in March, Medicare Part D plans can cover Wegovy for patients as long as they are obese or overweight, have a history of heart disease, and are specifically prescribed the weekly shot to reduce the risk of heart attacks. and strokes. The Food and Drug Administration approved Wegovy for that purpose in March.
KFF said that applies to 3.6 million, or 7%, of total beneficiaries, based on 2020 data. That group also makes up 1 in 4 of the 13.7 million Medicare patients who are obese or have overweight. Those numbers may be higher based on more recent data, the nonprofit group said.
Analysis suggests that, for the first time, certain Medicare beneficiaries will be able to access Nordisk's Wegovy without having to bear only the total monthly price of $1,300.
Notably, Medicare prescription drug plans run by private insurers, known as Part D, currently cannot cover Wegovy and other GLP-1 weight-loss-only drugs. GLP-1s are an active class of obesity and diabetes treatments that work by mimicking a hormone produced in the intestine to suppress a person's appetite and regulate blood sugar.
But KFF's analysis found that Medicare beneficiaries taking Wegovy could still face monthly out-of-pocket costs of $325 to $430 if they have to pay a percentage of the drug's list price for a month's supply.
A new Part D limit on out-of-pocket spending would limit beneficiaries' out-of-pocket costs to about $3,300 in 2024 and $2,000 in 2025. Still, those sums are a significant burden for those living on modest incomes.
Some patients may also have difficulty accessing Wegovy if the Part D plans that choose to cover it implement certain requirements to control costs and ensure the drug is used appropriately. That could include “step therapy,” which requires plan members to try other lower-cost medications or means to lose weight before using a GLP-1 like Wegovy.
“These factors could have a dampening effect on use by Medicare beneficiaries, even among the target population,” KFF wrote in its analysis.
Some Part D plans have already announced that they will begin covering Wegovy this year, but it is unclear how widespread coverage will be. KFF said many plans may be reluctant to expand coverage now because they cannot adjust their premiums mid-year to account for the higher costs associated with using the drug.
That means broader coverage could be more likely in 2025, KFF added.
Medicare already covers GLP-1 and other diabetes treatments, such as Novo Nordisk's blockbuster Ozempic.
Among Medicare beneficiaries who are obese or overweight and have a history of heart disease, 1.9 million also have diabetes, according to KFF. That makes them already eligible for Medicare coverage of other GLP-1 drugs approved for that condition.
