According to an analysis released Wednesday by the health policy research organization KFF, over 3 million Medicare recipients could become eligible for coverage of Wegovy, now that this blockbuster weight loss drug is also approved in the U.S. for heart health.
However, some eligible beneficiaries might still face out-of-pocket expenses for the highly popular and costly drug, as noted by KFF. Certain Medicare prescription drug plans may delay covering Wegovy until 2025.
As more plans cover the costs of Wegovy, Medicare’s budget could be significantly impacted.
KFF estimates that if just 10% of the eligible population, approximately 360,000 people, use the drug for a full year, the program’s prescription drug plans could incur an additional net expenditure of $2.8 billion.
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 prescribed the weekly injection to reduce their risk of heart attacks and strokes. The Food and Drug Administration approved Wegovy for this purpose in March.
KFF reported that this applies to 3.6 million, or 7%, of total beneficiaries, based on 2020 data. This group also constitutes 1 in 4 of the 13.7 million Medicare patients who are obese or overweight. These numbers could be higher with more recent data, according to the nonprofit group.
The analysis indicates that, for the first time, certain Medicare beneficiaries will be able to access Novo Nordisk’s Wegovy without bearing the entire $1,300 monthly cost alone.
Notably, Medicare prescription drug plans, known as Part D, currently cannot cover Wegovy and other GLP-1 drugs for weight loss alone.
GLP-1s are a popular class of obesity and diabetes treatments that work by mimicking a hormone produced in the gut to suppress appetite and regulate blood sugar.
However, KFF’s analysis found that Medicare beneficiaries who take Wegovy might still face monthly out-of-pocket costs of $325 to $430 if they have to pay a percentage of the drug’s list price.
A new Part D cap on out-of-pocket spending would limit beneficiaries’ costs to around $3,300 in 2024 and $2,000 in 2025. Nonetheless, these amounts are a significant burden for those on modest incomes.
Some patients may also find it challenging to access Wegovy if Part D plans that choose to cover it impose certain requirements to control costs and ensure appropriate usage.
This could include “step therapy,” requiring plan members to try other lower-cost medications or weight loss methods 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 stated in its analysis.
While some Part D plans have announced they will begin covering Wegovy this year, the extent of coverage remains uncertain.
KFF noted that many plans may be hesitant to expand coverage now, as they cannot adjust their premiums mid-year to account for the higher costs associated with the drug’s use.
Therefore, broader coverage in 2025 seems more likely, KFF added.
Medicare already covers GLP-1s and other treatments for diabetes, such as Novo Nordisk’s blockbuster Ozempic.
Among the Medicare beneficiaries who are obese or overweight and have a history of heart disease, 1.9 million also have diabetes, according to KFF.
This makes them already eligible for Medicare coverage of other GLP-1 drugs approved for diabetes.
