Weight administration medicines, together with Wegovy, Zepbound and Foundayo, will probably be obtainable to eligible Medicare beneficiaries with a $50 copay beginning July.
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Beginning in July, Medicare beneficiaries could possibly get a GLP-1 prescription for weight reduction for $50 a month. It is a notable shift for Medicare, which has lengthy been barred from masking weight reduction therapies.
The medicine, reminiscent of Wegovy and Zepbound, are efficient however could be costly with out insurance coverage protection. They’re obtainable in injection or tablet kind. Even with reductions, present money costs usually vary from $149 to $699 per thirty days.
About half of GLP-1 customers say these medicine had been tough for them to afford, based on KFF polling. 1 / 4 mentioned they had been “very tough” to afford.
However the brand new Medicare profit comes with caveats, notably round scientific tips and what occurs when the short-term program ends.
What is that this program?
The initiative, introduced by the Facilities for Medicare & Medicaid Companies, or CMS, is a short-term pilot program generally known as the Medicare GLP-1 Bridge. It’s going to run from July 1, 2026, by Dec. 31, 2027. It is meant to “bridge” the hole earlier than a longer-term program which may — or may not — start in 2028.
The pilot program will supply protection for the next GLP-1 medicines permitted for weight reduction: the tablet and injectable formulations of Wegovy, the KwikPen formulation of Zepbound, and the Foundayo tablet.
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 reminiscent of 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 this system works (it is a bit uncommon)
This isn’t your typical Medicare profit. Though Half D enrollment is required, the Bridge program itself works otherwise.
As a substitute of going by your common Half D plan, you will want 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 do not have to be enrolled as Medicare suppliers to put in writing a prescription or submit a previous authorization request underneath this program. As soon as they get approval, sufferers can pay the flat $50 copayment on the pharmacy once they choose up the prescription.
What are the advantages?
The associated fee financial savings may make these medicine accessible to sufferers who merely could not afford them earlier than. Even with reductions, the costs could be daunting with out insurance coverage protection. TrumpRx, a brand new authorities web site, offers hyperlinks to direct-to-consumer prescription drug reductions for sufferers not utilizing their medical health insurance.
On that web site, 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 per thirty days. On the highest dosages, the each day Wegovy tablet 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 gives a predictable $50 copayment that doesn’t go up as dosages enhance.
What are the downsides?
Like many pilot packages, there are trade-offs. The $50 copay won’t depend towards the Half 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 research have proven that many individuals who cease utilizing the GLP-1 medicine regain weight they misplaced whereas taking them.
It nonetheless could not really feel reasonably priced to individuals with low incomes
When you obtain the low-income subsidy, often known as the Medicare Additional Assist program, you can not 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 prescription drugs, a $50 copay may nonetheless be an enormous monetary barrier.
“Fifty {dollars} a month seems like an awesome deal in comparison with paying the discounted costs by TrumpRx and these different direct-to-consumer choices, but it surely’s some huge cash for any individual who’s dwelling on a $750-a-month Social Safety verify,” mentioned Juliette Cubanski, deputy director of the Program on Medicare Coverage at KFF, a well being info nonprofit that features KFF Well being Information.
The $50 copay is just for weight reduction
When you’re already taking one in all these medicines for a qualifying situation reminiscent of Sort 2 diabetes, heart problems threat discount, or sleep apnea, you will proceed to get it by your common Half D plan. Which means you will pay your plan’s worth, which can be larger than the $50 Bridge copay, which means the identical drug may value totally different quantities relying on the explanation it’s prescribed.
When 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 simply met the scientific standards once you first began the remedy. For instance, for those who began a GLP-1 in September 2024 with a BMI of 37 however in July 2026 you have 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 occurs after 2027?
The Trump administration had proposed a two-step strategy to broaden 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 might shift the price of the medicine from the federal government to insurers. A latest research 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 a substitute introduced it might 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 for weight reduction throughout the Bridge program and extra time to barter with the Trump administration.
However extending the Bridge program will probably be “actually costly” for Medicare, Cubanski mentioned, as a result of this system closely subsidizes the price of the medicine.
“There is no sense proper now of the price of the Bridge mannequin, however it’s prone to be billions of {dollars} a 12 months in further spending for Medicare,” Cubanski mentioned.
The associated fee to Medicare will rely largely on how many individuals use the Bridge program. CMS has not offered any projections publicly, however a earlier KFF evaluation estimated that in 2020 near 14 million Medicare beneficiaries had been obese or overweight.
“It will simply value further cash, and we do not know the way a lot, as a result of they have not disclosed it,” Cubanski mentioned.
Are you on Medicare and excited by getting a GLP-1 for weight reduction? Is a $50 copay manageable? Click on right here to contact KFF Well being Information’ reporting group.
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF.
