More than 3 million people with Medicare could qualify for Wegovy coverage now that the blockbuster weight loss drug has also been approved in the U.S. for heart health, according to an analysis released Wednesday by health policy research organization KFF.
But some eligible beneficiaries may still face out-of-pocket costs for the highly popular and expensive drug, KFF said. Certainly Medicare prescription drug plans may also wait until 2025 to cover Wegovy.
Medicare's budget could come under pressure as more plans cover Wegovy's costs. According to KFF, the program's drug plans could spend an additional $2.8 billion net if just 10% of the eligible population, an estimated 360,000 people, took the drug for a full year.
Under new guidelines issued in March, Medicare Part D plans can cover Wegovy for patients as long as they are obese or overweight, have a history of heart disease and are specifically prescribed the weekly shot to reduce their risk of heart attacks and strokes. The Food and Drug Administration approved Wegovy for that purpose in March.
KFF said this applies to 3.6 million, or 7%, of total beneficiaries, based on 2020 data. That group also makes up 1 in 4 of the 13.7 million Medicare patients who are obese or overweight . These numbers may be higher based on more recent data, the nonprofit said.
The analysis shows that for the first time, certain Medicare beneficiaries will have access Novo Nordisk's Wegovy without having to bear the total monthly price tag of $1,300 alone.
Notably, the Medicare prescription drug plans administered by private insurers, known as Part D, currently cannot cover Wegovy and other GLP-1 weight loss-only medications. GLP-1s are a buzzing class of obesity and diabetes treatments that work by mimicking a hormone produced in the intestines to suppress a person's appetite and regulate blood sugar levels.
But KFF's analysis found that Medicare beneficiaries using Wegovy could still face monthly out-of-pocket costs of $325 to $430 if they have to pay a percentage of the drug's list price for a month's supply.
A new Part D limit on out-of-pocket expenses would limit beneficiaries' out-of-pocket costs to about $3,300 in 2024 and $2,000 in 2025. Still, these amounts pose a significant burden for those living on modest incomes.
Some patients may also have difficulty accessing Wegovy if the Part D plans that decide to provide this coverage implement certain requirements to control costs and ensure the drug is used appropriately. That could include “step therapy,” which requires plan members to try other, cheaper medications or weight loss methods before taking a GLP-1 like Wegovy.
“These factors may have a dampening effect on utilization among Medicare beneficiaries, even among the target population,” KFF wrote in its analysis.
Some Part D plans have already announced they will cover Wegovy this year, but it's unclear how widespread the coverage will be. KFF said many plans may now be reluctant to expand coverage because they cannot adjust their premiums mid-year to account for the higher costs associated with using the drug.
That means broader coverage could be more likely in 2025, KFF added.
Medicare already covers GLP-1s and other treatments for diabetes, such as Novo Nordisk's blockbuster Ozempic.
Of Medicare beneficiaries who are obese or overweight and have a history of heart disease, 1.9 million also have diabetes, according to KFF. That already makes them eligible for Medicare coverage of other GLP-1 drugs approved for that condition.