Starting in July, Medicare beneficiaries might be able to get a GLP-1 prescription for weight reduction for $50 a month. It’s a notable shift for Medicare, which has lengthy been barred from masking weight reduction remedies.
The medication, equivalent to Wegovy and Zepbound, are efficient however may be costly with out insurance coverage protection. They’re out there in injection or tablet kind. Even with reductions, present money costs usually vary from $149 to $699 per 30 days.
About half of GLP-1 customers say these medication had been troublesome for them to afford, in response to KFF polling. 1 / 4 stated they had been “very difficult” to afford.
But the brand new Medicare profit comes with caveats, notably round medical pointers and what occurs when the short-term program ends.
What Is This Program?
The initiative, introduced by the Centers for Medicare & Medicaid Services, is a short-term pilot program generally known as the Medicare GLP-1 Bridge. It will run from July 1, 2026, by way of Dec. 31, 2027. It’s meant to “bridge” the hole earlier than a longer-term program that may — or won’t — start in 2028.
The pilot program will supply protection for the next GLP-1 drugs accredited for weight reduction: the tablet and injectable formulations of Wegovy, the KwikPen formulation of Zepbound, and the Foundayo tablet.
Who Can Participate?
To get entry to those weight reduction drugs, you have to be enrolled in a Medicare Part D plan, which covers prescribed drugs. After that, eligibility is predicated primarily on physique weight and well being standing. People will qualify if they’ve a body mass index of 27 or greater and have a situation equivalent to coronary heart illness or prediabetes, amongst others. People with BMIs of 35 or greater routinely qualify. About 40% of American adults are clinically overweight, with a BMI of 30 or greater, in response to the Centers for Disease Control and Prevention.
Email Sign-Up
How the Program Works (It’s a Bit Unusual)
This isn’t your typical Medicare profit. Even although Part D enrollment is required, the Bridge program itself works in another way.
Instead of going by way of your common Part D plan, you have to prior authorization. Your physician will ship the prescription to a central system run by CMS contractor Humana, utilizing a system already in place for an additional Medicare drug program. Doctors don’t should be enrolled as Medicare suppliers to jot down a prescription or submit a previous authorization request beneath this program. Once they get approval, sufferers pays the flat $50 copayment on the pharmacy once they choose up the prescription.
What Are the Benefits?
The price financial savings may make these medication accessible to sufferers who merely couldn’t afford them earlier than. Even with reductions, the costs may be daunting with out insurance coverage protection. TrumpRx, a brand new authorities web site, supplies hyperlinks to direct-to-consumer prescription drug reductions for sufferers not utilizing their medical health insurance. On that website, Wegovy injectables vary in value from $199 for a decrease dosage for the primary two months to $399 for a better dosage. The KwikPen formulation of Zepbound prices as much as $699 per 30 days. At the very best dosages, the day by day Wegovy tablet prices as much as $299 whereas Foundayo tops out at $349.
Most individuals who use these medication will want a better dose to take care of weight reduction. The Bridge program is exclusive in that it provides a predictable $50 copayment that doesn’t go up as dosages enhance.
What Are the Downsides?
Like many pilot applications, there are trade-offs. The $50 copay is not going to depend towards the Part D deductible, nor does it depend towards the $2,100 annual out-of-pocket cap on prescription drug prices. The pilot program may also finish in December 2027. Most studies have shown that many individuals who cease utilizing the GLP-1 medication regain weight they misplaced whereas taking them.
Still Obstacles for Those With Low Incomes
If you obtain the low-income subsidy, also referred to as the Medicare Extra Help program, you can not use that help for the medication lined by the GLP-1 Bridge program. For beneficiaries accustomed to paying a $5 or $10 copay for his or her prescription drugs, a $50 copay may nonetheless be a giant monetary barrier.
“Fifty dollars a month sounds like a great deal compared to paying the discounted prices through TrumpRx and these other direct-to-consumer options, but it’s a lot of money for somebody who’s living on a $750-a-month Social Security check,” stated Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a well being data nonprofit that features KFF Health News.
The $50 Copay Is Only for Weight Loss
If you’re already taking one among these drugs for a qualifying situation equivalent to Type 2 diabetes, heart problems threat discount, or sleep apnea, you’ll proceed to get it by way of your common Part D plan. That means you’ll pay your plan’s value, which can be greater than the $50 Bridge copay, which means the identical drug may price totally different quantities relying on the rationale it’s prescribed.
If you’re already on a GLP-1 for weight reduction, chances are you’ll qualify for the Bridge program. Your prescriber might want to attest that you simply met the medical standards whenever you first began the remedy. For instance, should you began a GLP-1 in September 2024 with a BMI of 37 however in July 2026 you’ve misplaced weight and now have a BMI of 34, the prescriber ought to attest within the prior authorization request that you simply met the BMI standards of 35 or over when the GLP-1 remedy began.
What Happens After 2027?
The Trump administration had proposed a two-step method to develop protection of GLP-1s for weight problems in Medicare. The Bridge program was initially deliberate to final six months — after that, the thought was to launch a longer-term program that may shift the price of the medication from the federal government to insurers. A recent study discovered the long-term program would have price insurance coverage corporations billions of {dollars} within the first yr. Not sufficient insurers signed on for the voluntary plan by the April deadline, so CMS as an alternative introduced it might lengthen the Bridge program to 18 months, with a brand new finish date of December 2027.
The transfer will give insurance coverage corporations extra knowledge on how many individuals with Medicare get GLP-1 medication throughout the Bridge program and extra time to barter with the Trump administration.
But extending the Bridge program might be “really expensive” for Medicare, Cubanski stated, as a result of this system closely subsidizes the price of the medication.
“There’s no sense right now of the cost of the Bridge model, but it is likely to be billions of dollars a year in additional spending for Medicare,” Cubanski stated.
The price to Medicare will rely largely on how many individuals use the Bridge program. CMS has not offered any projections publicly, however a previous KFF analysis estimated that in 2020 near 14 million Medicare beneficiaries had been chubby or overweight.
“This will just cost additional money, and we don’t know how much, because they haven’t disclosed it,” Cubanski stated.
Are you on Medicare and eager about getting a GLP-1 for weight reduction? Is a $50 copay manageable? Click here to contact KFF Health News’ reporting staff.
