Beginning in July, Medicare beneficiaries might be able to get a GLP-1 prescription for weight reduction for $50 a month. It’s a notable shift for Medicare, which has lengthy been barred from protecting weight reduction therapies.
The medication, resembling Wegovy and Zepbound, are efficient however might be costly with out insurance coverage protection. They’re out there in injection or capsule kind. Even with reductions, present money costs usually vary from $149 to $699 per thirty days.
About half of GLP-1 customers say these medication have been troublesome for them to afford, in accordance with KFF polling. 1 / 4 stated they have been “very troublesome” to afford.
However the brand new Medicare profit comes with caveats, notably round scientific pointers and what occurs when the short-term program ends.
What Is This Program?
The initiative, introduced by the Facilities for Medicare & Medicaid Companies, is a short-term pilot program often known as the Medicare GLP-1 Bridge. It should run from July 1, 2026, by Dec. 31, 2027. It’s meant to “bridge” the hole earlier than a longer-term program that may — or won’t — start in 2028.
The pilot program will provide protection for the next GLP-1 medicines accredited for weight reduction: the capsule and injectable formulations of Wegovy, the KwikPen formulation of Zepbound, and the Foundayo capsule.
Who Can Take part?
To get entry to those weight reduction medicines, you have to be enrolled in a Medicare Half D plan, which covers prescribed drugs. After that, eligibility is predicated primarily on physique weight and well being standing. Folks will qualify if they’ve a physique mass index of 27 or greater and have a situation resembling coronary heart illness or prediabetes, amongst others. Folks with BMIs of 35 or greater mechanically qualify. About 40% of American adults are clinically overweight, with a BMI of 30 or greater, in accordance with the Facilities for Illness Management and Prevention.
How the Program Works (It’s a Bit Uncommon)
This isn’t your typical Medicare profit. Despite the fact that Half D enrollment is required, the Bridge program itself works in another way.
As an alternative of going by your common Half D plan, you’ll need prior authorization. Your physician will ship the prescription to a central system run by CMS contractor Humana, utilizing a system already in place for one more Medicare drug program. Medical doctors don’t must be enrolled as Medicare suppliers to jot down a prescription or submit a previous authorization request below this program. As soon as they get approval, sufferers can pay the flat $50 copayment on the pharmacy after they choose up the prescription.
What Are the Advantages?
The fee financial savings might make these medication accessible to sufferers who merely couldn’t afford them earlier than. Even with reductions, the costs might be daunting with out insurance coverage protection. TrumpRx, a brand new authorities web site, gives hyperlinks to direct-to-consumer prescription drug reductions for sufferers not utilizing their medical health insurance. On that web site, Wegovy injectables vary in value from $199 for a decrease dosage for the primary two months to $399 for a better dosage. The KwikPen formulation of Zepbound prices as much as $699 per thirty days. On the highest dosages, the day by day Wegovy capsule prices as much as $299 whereas Foundayo tops out at $349.
Most individuals who use these medication will want a better dose to take care of weight reduction. The Bridge program is exclusive in that it gives a predictable $50 copayment that doesn’t go up as dosages enhance.
What Are the Downsides?
Like many pilot applications, there are trade-offs. The $50 copay won’t depend towards the Half D deductible, nor does it depend towards the $2,100 annual out-of-pocket cap on prescription drug prices. The pilot program may also finish in December 2027. Most research have proven that many individuals who cease utilizing the GLP-1 medication regain weight they misplaced whereas taking them.
Nonetheless Obstacles for These With Low Incomes
Should you obtain the low-income subsidy, also called the Medicare Additional Assist program, you can’t use that help for the medication lined by the GLP-1 Bridge program. For beneficiaries accustomed to paying a $5 or $10 copay for his or her prescribed drugs, a $50 copay might nonetheless be a giant monetary barrier.
“Fifty {dollars} a month appears like a fantastic deal in comparison with paying the discounted costs by TrumpRx and these different direct-to-consumer choices, nevertheless it’s some huge cash for someone who’s residing on a $750-a-month Social Safety examine,” stated Juliette Cubanski, deputy director of the Program on Medicare Coverage at KFF, a well being info nonprofit that features KFF Well being Information.
The $50 Copay Is Just for Weight Loss
Should you’re already taking one in all these medicines for a qualifying situation resembling Kind 2 diabetes, heart problems danger discount, or sleep apnea, you’ll proceed to get it by your common Half D plan. Meaning you’ll pay your plan’s value, which can be greater than the $50 Bridge copay, that means the identical drug might value totally different quantities relying on the rationale it’s prescribed.
Should you’re already on a GLP-1 for weight reduction, chances are you’ll qualify for the Bridge program. Your prescriber might want to attest that you just met the scientific standards if you first began the treatment. For instance, for those who began a GLP-1 in September 2024 with a BMI of 37 however in July 2026 you’ve misplaced weight and now have a BMI of 34, the prescriber ought to attest within the prior authorization request that you just met the BMI standards of 35 or over when the GLP-1 remedy began.
What Occurs After 2027?
The Trump administration had proposed a two-step method to increase protection of GLP-1s for weight problems in Medicare. The Bridge program was initially deliberate to final six months — after that, the concept was to launch a longer-term program that might shift the price of the medication from the federal government to insurers. A current examine discovered the long-term program would have value insurance coverage firms billions of {dollars} within the first 12 months. Not sufficient insurers signed on for the voluntary plan by the April deadline, so CMS as an alternative introduced it could prolong the Bridge program to 18 months, with a brand new finish date of December 2027.
The transfer will give insurance coverage firms extra knowledge on how many individuals with Medicare get GLP-1 medication through the Bridge program and extra time to barter with the Trump administration.
However extending the Bridge program shall be “actually costly” for Medicare, Cubanski stated, as a result of this system closely subsidizes the price of the medication.
“There’s no sense proper now of the price of the Bridge mannequin, however it’s prone to be billions of {dollars} a 12 months in extra spending for Medicare,” Cubanski stated.
The fee to Medicare will rely largely on how many individuals use the Bridge program. CMS has not offered any projections publicly, however a earlier KFF evaluation estimated that in 2020 near 14 million Medicare beneficiaries have been obese or overweight.
“This may simply value extra cash, and we don’t understand how a lot, as a result of they haven’t disclosed it,” Cubanski stated.
Are you on Medicare and occupied with getting a GLP-1 for weight reduction? Is a $50 copay manageable? Click on right here to contact KFF Well being Information’ reporting workforce.
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