Beginning 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 medicine, akin to Wegovy and Zepbound, are efficient however may be costly with out insurance coverage protection. They’re obtainable in injection or capsule kind. Even with reductions, present money costs usually vary from $149 to $699 monthly.
About half of GLP-1 customers say these medicine have been troublesome for them to afford, based on KFF polling. 1 / 4 mentioned they have been “very troublesome” to afford.
However the brand new Medicare profit comes with caveats, significantly round scientific tips and what occurs when the short-term program ends.
What Is This Program?
The initiative, introduced by the Facilities for Medicare & Medicaid Providersis a short-term pilot program often known as the Medicare GLP-1 Bridge. It’ll run from July 1, 2026, by means of Dec. 31, 2027. It’s meant to “bridge” the hole earlier than a longer-term program that may — or may not — start in 2028.
The pilot program will supply protection for the next GLP-1 medicines accepted for weight reduction: the capsule and injectable formulations of Wegovy, the KwikPen formulation of Zepbound, and the Foundayo capsule.
Who Can Take part?
To get entry to those weight reduction medicines, you should be enrolled in a Medicare Half D plan, which covers prescribed drugs. After that, eligibility relies primarily on physique weight and well being standing. Individuals will qualify if they’ve a physique mass index of 27 or larger and have a situation akin to coronary heart illness or prediabetes, amongst others. Individuals with BMIs of 35 or larger robotically qualify. About 40% of American adults are clinically overweight, with a BMI of 30 or larger, based on the Facilities for Illness Management and Prevention.
How the Program Works (It’s a Bit Uncommon)
This isn’t your typical Medicare profit. Despite the fact that Half D enrollment is required, the Bridge program itself works in a different way.
As an alternative of going by means of your common Half 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 one more Medicare drug program. Docs don’t should be enrolled as Medicare suppliers to jot down a prescription or submit a previous authorization request beneath this program. As soon as they get approval, sufferers can pay the flat $50 copayment on the pharmacy once they decide up the prescription.
What Are the Advantages?
The price financial savings might make these medicine 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, gives hyperlinks to direct-to-consumer prescription drug reductions for sufferers not utilizing their medical health insurance. On that website, Wegovy injectables vary in worth from $199 for a decrease dosage for the primary two months to $399 for the next dosage. The KwikPen formulation of Zepbound prices as much as $699 monthly. On the highest dosages, the each day Wegovy capsule prices as much as $299 whereas Foundayo tops out at $349.
Most individuals who use these medicine will want the next dose to take care of weight reduction. The Bridge program is exclusive in that it affords a predictable $50 copayment that doesn’t go up as dosages improve.
What Are the Downsides?
Like many pilot packages, there are trade-offs. The $50 copay is not going to rely towards the Half D deductible, nor does it rely towards the $2,100 annual out-of-pocket cap on prescription drug prices. The pilot program may also finish in December 2027. Most research have proven that many individuals who cease utilizing the GLP-1 medicine regain weight they misplaced whereas taking them.
Nonetheless Obstacles for These With Low Incomes
In case you obtain the low-income subsidy, also called the Medicare Additional Assist program, you can’t use that help for the medicine lined by the GLP-1 Bridge program. For beneficiaries accustomed to paying a $5 or $10 copay for his or her prescribed drugs, a $50 copay might nonetheless be an enormous monetary barrier.
“Fifty {dollars} a month appears like an ideal deal in comparison with paying the discounted costs by means of TrumpRx and these different direct-to-consumer choices, nevertheless it’s some huge cash for any individual who’s residing on a $750-a-month Social Safety test,” mentioned Juliette Cubanski, deputy director of the Program on Medicare Coverage at KFF, a well being data nonprofit that features KFF Well being Information.
The $50 Copay Is Just for Weight Loss
In case you’re already taking one among these medicines for a qualifying situation akin to Kind 2 diabetes, heart problems threat discount, or sleep apnea, you’ll proceed to get it by means of your common Half D plan. Which means you’ll pay your plan’s worth, which can be larger than the $50 Bridge copay, that means the identical drug might value totally different quantities relying on the explanation it’s prescribed.
In case you’re already on a GLP-1 for weight reduction, you could qualify for the Bridge program. Your prescriber might want to attest that you just met the scientific standards whenever you first began the treatment. For instance, for those who 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 just met the BMI standards of 35 or over when the GLP-1 remedy began.
What Occurs After 2027?
The Trump administration had proposed a two-step method to broaden protection of GLP-1s for weight problems in Medicare. The Bridge program was initially deliberate to final six months — after that, the concept was to launch a longer-term program that might shift the price of the medicine from the federal government to insurers. A current examine discovered the long-term program would have value insurance coverage firms billions of {dollars} within the first 12 months. Not sufficient insurers signed on for the voluntary plan by the April deadline, so CMS as an alternative introduced it could prolong the Bridge program to 18 months, with a brand new finish date of December 2027.
The transfer will give insurance coverage firms extra knowledge on how many individuals with Medicare get GLP-1 medicine in the course of the Bridge program and extra time to barter with the Trump administration.
However extending the Bridge program might be “actually costly” for Medicare, Cubanski mentioned, as a result of this system closely subsidizes the price of the medicine.
“There’s no sense proper now of the price of the Bridge mannequin, however it’s more likely to be billions of {dollars} a 12 months in further spending for Medicare,” Cubanski mentioned.
The price to Medicare will rely largely on how many individuals use the Bridge program. CMS has not supplied any projections publicly, however a earlier KFF evaluation estimated that in 2020 near 14 million Medicare beneficiaries have been chubby or overweight.
“This can simply value further cash, and we don’t know the way a lot, as a result of they haven’t disclosed it,” Cubanski mentioned.
Are you on Medicare and fascinated by getting a GLP-1 for weight reduction? Is a $50 copay manageable? Click on right here to contact KFF Well being Information’ reporting workforce.
