More plans covering Wegobee’s costs could put pressure on Medicare’s budget. If just 10% of the eligible population (estimated at 360,000 people) used the drug for a year, the program’s prescription drug plans could cost an additional $2.8 billion, according to KFF.
Under new guidance issued in March, Medicare Part D plans require patients who are obese or overweight and have a history of heart disease to receive special weekly injections to reduce their risk of heart attack or stroke. Wegovy can be applied to patients as long as it is prescribed. The Food and Drug Administration approved Wegovy for that purpose in March.
KFF said that based on 2020 data, this applies to 7% of all beneficiaries, or 3.6 million people. This group accounts for one in four of the 13.7 million Medicare patients who are obese or overweight. Based on more recent data, those numbers could be even higher, the nonprofit said.
This analysis suggests that for the first time, certain Medicare beneficiaries will be able to access Novo Nordisk’s Wegovy without having to pay a total of $1,300 per month alone.
Notably, Medicare prescription drug plans run by private insurers known as Part D currently cannot cover Wegovy or other GLP-1 drugs solely for weight loss. GLP-1 is a well-known obesity and diabetes treatment that works by mimicking hormones produced in the intestines to suppress appetite and regulate blood sugar levels.
However, KFF’s analysis shows that Medicare beneficiaries taking Wegovy still face monthly out-of-pocket costs of $325 to $430, no matter what percentage of the drug’s list price they have to pay for a month’s worth. may be faced.
New Part D caps on out-of-pocket costs would limit beneficiaries’ out-of-pocket costs to about $3,300 in 2024 and $2,000 in 2025. Still, this amount is a heavy burden for people living on modest incomes.
Also, if you decide to cover Wegovy in your Part D plan and decide to implement specific requirements to control costs and ensure the drug is used appropriately, some Patients may have difficulty accessing Wegovy. This could include “step therapy,” which requires plan members to try other lower-cost drugs or weight loss measures before using GLP-1, such as Wegovy.
“These factors may dampen uptake among eligible Medicare beneficiaries,” KFF said in its analysis.
Some Part D plans already announced Coverage of Wegovy is scheduled to begin this year, but it is unclear how widely it will be covered. KFF notes that many insurance plans may be reluctant to expand coverage at this time because they are unable to adjust premiums mid-year to account for increased costs associated with the drug’s use. said.
This means it is likely to be even more widely applied in 2025, KFF added.
Medicare already covers diabetes drugs such as GLP-1 and Novo Nordisk’s blockbuster Ozempic.
According to KFF, 1.9 million Medicare beneficiaries who are obese or overweight and have a history of heart disease also have diabetes. This already qualifies them for Medicare coverage of other her GLP-1 drugs approved for that condition.
