Cost of GLP-1 Weight Loss Drug Reduced for Older Americans

NEW YORK — A popular yet expensive weight loss medication known as GLP-1 has become significantly more affordable for many older Americans.

Beginning Wednesday, the federal government is introducing a program that allows select brand-name medications to be accessed by certain individuals. Medicare and Medicare Advantage beneficiaries can now obtain this treatment for just $50 a month through a new initiative called Medicare GLP-1 Bridge.

This temporary program will last until the end of 2027, marking the first time many older adults can obtain GLP-1, which stands for glucagon-like peptide-1 receptor agonist. While this medication is typically covered by insurance for weight loss purposes, there are health criteria that prevent those already receiving it for conditions like diabetes or sleep apnea from participating.

Administrators at the Centers for Medicare and Medicaid Services expressed hope that the initiative would not only provide immediate financial relief but also help them gather data for longer-term coverage. “The high price of these drugs creates significant barriers,” said a representative on a call.

Eligibility Criteria for the Program

Out of over 70 million Americans on Medicare, at least 10 million are categorized as overweight or obese, according to Juliet Cubansky, vice president and director of Medicare policy programs. However, only a smaller subset of this group is likely to qualify for the new program.

The exact number of beneficiaries who will benefit remains unclear, and officials are holding back on speculating about participation. The data collected will provide insights into how many eligible individuals choose to utilize the medication.

To qualify, individuals must have Medicare drug coverage and either a BMI of 35 or higher, or a BMI of 27 along with another health issue like a past heart attack or prediabetes. BMI measurements taken at the start of the therapy will determine eligibility, allowing those who can prove they had a higher BMI initially to qualify, even if their current BMI is lower.

Those with existing conditions such as sleep apnea or diabetes won’t be able to access this program, though Medicare Part D may cover GLP-1 separately based on these diagnoses.

The first step for potential participants is to consult their healthcare providers. A prescription for one of the covered GLP-1 drugs must be sent to a pharmacy along with a prior authorization form.

What Drugs Are Included

The program covers specific GLP-1 medications such as Eli Lilly’s Foundayo tablets, Zepbound KwikPens, and Novo Nordisk’s Wegovy injections and tablets, all of which have FDA approval for weight loss.

Participants will be required to pay $50 per month, regardless of dosage. Importantly, these payments will not count towards any insurance deductibles or out-of-pocket maximums since Medicare is subsidizing the prescriptions, not the Part D insurers.

Uncertain Future for GLP-1 in Medicare

This program is slated to conclude by December 31, 2027, and there’s currently no congressional authorization for permanent coverage of weight loss medications, which limits future access options.

Congress could potentially pass new legislation to allow for targeted drug coverage. Additionally, CMS may consider reviving a postponed voluntary testing program for the drug called BALANCE, although many Part D insurers were hesitant to participate earlier this year.

Officials indicated they will continue to monitor participation and results closely to assess the feasibility of extending the Bridge program or exploring alternative solutions. There’s a suggestion that discussions about permanent coverage options should take place in Congress moving forward.

Impact on Individuals

The popularity of GLP-1 medications has surged, helping many individuals achieve significant weight loss. However, the high costs, which can soar to several hundred dollars for larger doses, have been a substantial hurdle.

California resident Gloria Dorala, 78, shared that she has lost around 40 pounds after purchasing the affordable Wegovey in Europe, and she sees the Bridge program as crucial for continuing her treatment. “This drug should be affordable and accessible to everyone who struggles with weight loss,” she commented.

On the other hand, not everyone finds the drug within their financial reach. Katie Smith, a 71-year-old from Virginia, is uncertain about her eligibility. Although her BMI is 33, it’s unclear if she meets the additional health requirements.

Smith, whose ability to exercise has been severely limited due to a spinal cord injury, has considered medication but finds the estimated $700 monthly cost prohibitive. “I’m incredibly frustrated,” she expressed. “I have the willpower and determination, but conventional methods haven’t worked for me.”