Approximately 3.6 million Medicare beneficiaries now have the potential to access Wegovy, as the drug has been approved by the Food and Drug Administration (FDA) for reducing the risk of incidents related to cardiovascular disease.

In accordance with an analysis by KFF, a significant number of Medicare beneficiaries diagnosed with obesity also have cardiovascular disease. 

Medicare Recipients to Gain Weight Loss Drug Access

This group of potential beneficiaries accounts for approximately 7 percent of the total Medicare population. Medicare's budget may face challenges as an increasing number of plans start covering the expenses associated with Wegovy. 

According to The Hill, the program's prescription drug plans could potentially see an increase in spending by $2.8 billion if approximately 360,000 people, which is about 10% of the eligible population, use the drug for a full year.

Based on recent guidance released in March, Medicare Part D plans now have the ability to provide coverage for Wegovy to eligible patients. 

These patients must meet certain criteria, such as being obese or overweight, having a history of heart disease, and receiving a specific prescription for the weekly injection to lower their risk of heart attacks and strokes. 

It is worth mentioning that Part D, the Medicare prescription drug plans managed by private insurers, do not currently provide coverage for Wegovy and other GLP-1 drugs specifically for weight loss purposes. 

GLP-1s have gained significant attention as a class of treatments for obesity and diabetes. These medications function by imitating a hormone naturally produced in the gut, which helps to reduce appetite and stabilize blood sugar levels.

However, according to KFF's analysis, Medicare beneficiaries using Wegovy may still incur 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.

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Some Medicare Beneficiaries May Struggle to Obtain Wegovy

In 2024, beneficiaries would see a cap on their out-of-pocket spending at approximately $3,300. This cap would then decrease to $2,000 in 2025.  However, for individuals with lower incomes, those amounts can be quite burdensome.

Certain patients may face difficulties in obtaining Wegovy if Part D plans, which choose to cover it, impose specific criteria to manage expenses and ensure appropriate usage of the drug, CNBC reported.

That may involve "step therapy," where plan members are required to try alternative, less expensive medications or weight loss methods before using a GLP-1 like Wegovy.

Several Part D plans have already made announcements regarding the inclusion of Wegovy in their coverage for this year.  Based on KFF, some plans may be hesitant to increase coverage at this time due to their inability to adjust premiums during the year to accommodate the increased costs related to the drug.

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