In a recent decision, millions of Americans dealing with obesity were impacted when the Trump administration declined to permit Medicare and Medicaid to cover well-known weight loss medications such as Wegovy and Zepbound.
Last month, the Centers for Medicare and Medicaid Services (CMS) turned down a proposal from the Biden administration that sought coverage for these drugs. The most notable among these medications are Wegovy, produced by Novo Nordisk, and Zepbound, made by Eli Lilly.
Medicines designed for diabetes, including Ozempic and Mounjaro, are already covered by Medicare, albeit only for a limited group of obese patients who have conditions like heart disease or sleep apnea.
Additionally, state Medicaid programs are deciding whether to include GLP-1 drugs for obesity treatment, with 13 states having made that choice by August 2024.
The Biden-era initiative would have made these drugs more accessible financially for Medicare and Medicaid recipients without those specific health issues. It’s estimated by Medicare authorities that about 3.4 million beneficiaries would have benefitted from this coverage change.
Over 20% of Medicare enrollees are classified as obese, according to the U.S. Department of Health and Human Services (HHS).
Drugs in the GLP-1 agonist category are shown to help individuals lose up to 20% of their body weight and assist in preventing type 2 diabetes, as noted in reports.
WellCare, which provides Medicare advantages and prescription drug plans, has raised questions about individual drug costs and out-of-pocket expenses.
Recent price reductions have been observed, with both Novo Nordisk and Eli Lilly pricing their medications on a self-pay basis at approximately $350 to $500 each month.
Ozempic
Ozempic, known as Semaglutide, is used to regulate blood glucose levels. While Medicare Part D does cover Ozempic, it’s worth noting that it’s not specifically prescribed solely for weight loss.
Patients seeking it for weight loss must cover the cost themselves, which can reach about $998 per month.
Wegovy
Wegovy is the version of Ozempic designed for weight loss and requires patients to meet certain body mass index (BMI) criteria for eligibility. Like Ozempic, it’s an injectable form of semaglutide.
Although it’s not covered under Medicare for weight loss, the FDA approved its use for cardiovascular disease and among obese patients in early 2024.
The price tag for Wegovy is around $1,349 each month.
Mounjaro
Eli Lilly’s Mounjaro, approved by the FDA in 2017 for type 2 diabetes, utilizes tilzepitide instead of semaglutide to help manage blood sugar levels. However, it isn’t sanctioned solely for obesity, and Medicare doesn’t cover it for that usage.
The typical cost without insurance is approximately $1,079.
Zepbound
Zepbound, another Tirzepitide variant from Eli Lilly, is FDA-approved for chronic weight management and made history in December as the first drug to treat obstructive sleep apnea.
While Medicare covers Zepbound for sleep apnea, it does not provide coverage strictly for weight loss purposes. The regular price patients need to pay is about $1,086.
Despite the recent decision from the Trump administration, there’s still potential for Medicare to consider covering these medications in the future. The non-partisan Congressional Budget Office has indicated that expanding coverage could cost around $35 billion over the next decade.
