An analysis released by the health policy research organization KFF revealed that more than 3 million people with Medicare could potentially be eligible for coverage of Wegovy, a newly approved weight loss drug that also benefits heart health. While this is a positive development, there are still some challenges and limitations that eligible beneficiaries may face when it comes to accessing this costly drug through Medicare Part D plans.
According to KFF, Medicare’s budget could be strained as more plans start covering the costs of Wegovy. If just 10% of the eligible population, approximately 360,000 people, use the drug for a full year, Medicare prescription drug plans could spend an additional net $2.8 billion. This significant expenditure highlights the potential financial burden on the Medicare program as more beneficiaries opt for Wegovy.
While Medicare Part D plans can now cover Wegovy for eligible beneficiaries, there may still be out-of-pocket costs involved. Some Medicare beneficiaries who take Wegovy could face monthly out-of-pocket expenses ranging from $325 to $430 if they are required to pay a percentage of the drug’s list price for a month’s supply. For individuals with modest incomes, these costs could pose a significant financial challenge.
In addition to out-of-pocket costs, Medicare beneficiaries may also encounter challenges in accessing Wegovy through Part D plans. Some plans may implement requirements such as “step therapy” to control costs and ensure the appropriate use of the drug. Step therapy mandates that plan members try other lower-cost medications or weight loss methods before being prescribed Wegovy. These barriers could deter some beneficiaries from utilizing the drug, even among those who meet the eligibility criteria.
While some Part D plans have already announced that they will begin covering Wegovy, the extent of coverage remains uncertain. Many plans may be hesitant to expand coverage immediately due to the inability to adjust premiums mid-year to accommodate the higher costs associated with the drug. As a result, broader coverage of Wegovy under Medicare Part D plans may be more likely in 2025, allowing for more beneficiaries to access this weight loss treatment.
The approval of Wegovy for coverage under Medicare Part D plans presents both opportunities and challenges for eligible beneficiaries. While the drug offers a new treatment option for individuals struggling with obesity and heart disease, concerns around out-of-pocket costs, access barriers, and the strain on Medicare’s budget remain. Moving forward, it will be essential for policymakers, insurers, and healthcare providers to address these issues to ensure equitable and affordable access to Wegovy for those in need.