More than 3 million Medicare beneficiaries may be eligible for Wegovy coverage because the blockbuster weight-loss drug is also approved to treat heart health in the United States, according to an analysis released Wednesday by health policy research group KFF.
But KFF said some eligible beneficiaries may still face out-of-pocket costs for the popular and expensive drug.affim Medicare prescription drug plans also may have to wait until 2025 to cover Wegovy.
As more plans cover the cost of Wegovy, Medicare budgets may be tight. According to KFF, the program’s prescription drug program could incur an additional net expenditure of $2.8 billion if only 10% of the eligible population, an estimated 360,000 people, used the drug year-round.
Under new guidance released in March, Medicare Part D plans can cover Wegovy for patients who are obese or overweight, have a history of heart disease and are specifically prescribed weekly injections to reduce the risk of heart attacks and strokes. The U.S. Food and Drug Administration approved Wegovy for this purpose in March.
KFF said this applies to 3.6 million people, or 7% of total beneficiaries, based on 2020 data. This group also represents a quarter of the 13.7 million Medicare patients who are obese or overweight. The nonprofit said those numbers could be higher based on the latest data.
Analysis shows some Medicare beneficiaries will be able to get health insurance for the first time Novo Nordiskof Wegovy without having to bear the total price tag of $1,300 per month alone.
It’s worth noting that Wegovy and other GLP-1 drugs used only for weight loss are currently not covered by Medicare’s prescription drug plans (called Part D) administered by private insurance companies. GLP-1 is a popular class of obesity and diabetes treatments that suppresses appetite and regulates blood sugar in humans by mimicking hormones produced in the gut.
But KFF’s analysis found that Medicare beneficiaries taking Wegovy could still face out-of-pocket costs of $325 to $430 per month if they had to pay a percentage of the monthly drug’s list price.
The new Part D out-of-pocket cap will limit beneficiaries’ out-of-pocket expenses to about $3,300 in 2024 and $2,000 in 2025. heavy burden.
Some patients may also have difficulty getting Wegovy if the Part D plans that decide to cover Wegovy implement certain requirements to control costs and ensure the drug is used appropriately. This could include “step therapy,” which requires plan members to try other lower-cost medications or weight loss methods before using a GLP-1 like Wegovy.
“These factors may have a disincentive effect on utilization among Medicare beneficiaries, even among the target population,” KFF wrote in the analysis.
Some Part D plans have declare They will start covering Wegovy this year, but it’s unclear how widespread that coverage will be. KFF said many plans may be reluctant to expand coverage now because they cannot adjust premiums mid-year to account for the higher costs associated with using the drug.
This means wider coverage is more likely in 2025, KFF added.
Medicare already covers GLP-1 and other diabetes treatments, such as Novo Nordisk’s blockbuster drug 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. This makes them already eligible for Medicare coverage of other GLP-1 drugs approved for this condition.
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