Additional Coverage:
For the first time, Medicare will cover GLP-1 medications specifically for obesity-related weight loss, even when no other medical conditions are present.
Starting this Wednesday, eligible Medicare beneficiaries can obtain these prescriptions for $50 per month. Medicare, the primary federal health insurance program for Americans aged 65 and older, has traditionally excluded coverage for drugs prescribed solely to treat obesity under Part D, which covers prescription medications.
However, a new federal pilot program, authorized by Health and Human Services Secretary Robert F. Kennedy Jr., will temporarily bridge this gap until December 31, 2027. This initiative is expected to significantly broaden access to medications like Eli Lilly’s Foundayo and Zepbound, as well as Novo Nordisk’s Wegovy, for seniors and other qualified Medicare enrollees.
Foundayo and Wegovy are available as daily oral tablets, while Wegovy and Zepbound are administered as weekly injections requiring refrigeration. Wegovy comes in four pre-filled pens per monthly supply, and Zepbound is supplied in a KwikPen that contains four weekly doses in one device. It’s important to note that single-dose Zepbound pens and vials are not included in the coverage.
“These treatments represent a major medical advancement, yet many seniors currently face barriers due to high costs,” said Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services. “The Medicare GLP-1 Bridge program addresses this by making these medications more affordable and accessible, supporting our broader mission to help Americans lead healthier lives.”
According to a recent analysis by the Kaiser Family Foundation, approximately 3.8 million Medicare beneficiaries could qualify for this program. Negotiations with drug manufacturers have reduced the government’s cost to $250 per month’s supply, with patients responsible for a $50 copay. However, this copay does not count toward an individual’s annual deductible.
Before filling a prescription, patients must obtain prior authorization. Healthcare providers will need to submit documentation verifying that patients meet strict criteria based on body mass index (BMI) and health status.
Specifically, patients with a BMI of 35 or higher qualify. Those with a BMI between 30 and 35 must also have certain conditions such as heart failure, uncontrolled blood pressure, or chronic kidney disease.
For BMIs between 27 and 30, qualifying conditions include prediabetes, a history of heart attack or stroke, or peripheral artery disease.
These eligibility requirements are more stringent than those set by the FDA or many private insurers, which generally approve GLP-1 use for individuals with a BMI of 30 or higher.
Additionally, patients with type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease are excluded from this program, as their Medicare plans may already cover GLP-1 treatments.
“GLP-1s can be life-changing for patients managing obesity and related conditions,” stated Chris Klomp, Medicare director and chief counselor at the Department of Health and Human Services. “This demonstration aims to simplify access to these medications, making coverage more predictable and consistent across Medicare. Ultimately, this means improved quality of life for seniors and better value for the healthcare system.”
Approved prescriptions can be filled at local retail pharmacies or through direct-to-consumer mail-order services offered by Novo Nordisk and Eli Lilly.