Millions of Americans fighting obesity faced a setback last month when the Trump administration declined to allow Medicare and Medicaid to cover popular weight loss drugs like Wegovy and Zepbound.
The Centers for Medicare & Medicaid Services (CMS) last month rejected a proposal from the Biden administration that would have required Medicare and Medicaid to cover the drugs. According to The New York Times, the most popular of the drugs are Wegovy, made by Novo Nordisk, and Zepbound, made by Eli Lilly.
The drugs for diabetes are manufactured under the names Ozempic and Mounjaro. Medicare covers the medications for diabetic patients, as well as a small subset who are obese and have a heart condition or sleep apnea.
State Medicaid programs have the choice of whether or not to cover GLP-1 drugs for the treatment of obesity. As of August 2024, Medicaid programs in 13 states do so.
The Biden-era proposal would have made the drugs much more affordable for those Medicare and Medicaid patients with obesity who do not have those illnesses, the Times reported. Medicare officials estimated that about 3.4 million of its recipients would have benefited from the policy change.
More than 20 percent of Medicare recipients are obese, according to the U.S. Department of Health and Human Services (HHS).
Reuters reported that the medications, which fall into the GLP-1 agonist class of drugs, have been shown to help reduce a person’s weight by up to 20 percent. It can also help prevent the development of Type 2 diabetes.
Wellcare, which offers Medicare Advantage and Medicare Prescription Drug Plans, broke down the Medicare coverage of the individual drugs in question, as well as the out-of-pocket costs.
According to the Times, these costs were recently slashed, with both Novo Nordisk and Eli Lilly offering self-pay patients their products for between $350 and $500 per month.
Ozempic
Ozempic is a brand name for a drug known as semaglutide, which helps control blood glucose levels. Medicare Part D covers Ozempic, but the drug is not prescribed solely for weight loss.
Patients using the drug for that purpose would have to pay for the injections out of pocket. Novo Nordisk’s list price for the drug is $998 per month.
Wegovy
Wegovy is the company’s version of Ozempic for weight loss. Like Ozempic, it is an injectable form of semiglutide, according to Wellcare.
Wegovy, which is dosed differently than Ozempic, is FDA-approved to treat obesity, and patients must meet a certain body mass index, or BMI, to qualify for its use.
It is not covered for weight loss by Medicare, but the FDA in early 2024 approved its use for obese patients who also have cardiovascular disease.
The list cost for Wegovy is about $1,349 per month.
Mounjaro
Mounjaro, Eli Lilly’s drug for diabetes, was approved by the FDA in 2017 to help treat Type 2 diabetes. The medication, which is a tirzepitide instead of a semiglutide, similarly helps control a person’s blood glucose level.
It is not approved solely for obesity, however, and Medicare does not cover it for that purpose.
Without insurance, the cost is typically about $1,079, according to the manufacturer.
Zepbound
Zepbound, a second form of tirzepitide produced by Eli Lilly, is FDA approved for chronic weight management. In December, it became the first FDA-approved drug for the treatment of obstructive sleep apnea.
Because it is approved to treat sleep apnea, Medicare covers Zepbound for that purpose. It does not cover it solely for weight loss.
Patients paying the list price for the medication would pay about $1,086.
Despite last month’s decision by the Trump administration, there is a chance that the drugs could be covered in the future by Medicare. The nonpartisan Congressional Budget Office determined that the expansion of coverage would cost about $35 billion over 10 years, according to the Times.
