The recent approval of Wegovy in the U.S. for heart health has opened doors for more than 3 million people with Medicare to potentially access this popular weight loss drug. According to a recent analysis by KFF, Medicare beneficiaries who are obese or overweight, have a history of heart disease, and are prescribed Wegovy to reduce their risk of heart attacks and strokes are eligible for coverage under Part D plans. This represents a significant portion of the total Medicare population, with 3.6 million individuals meeting the criteria based on 2020 data.
While the approval of Wegovy for heart health is a positive development for Medicare beneficiaries, there are still financial challenges to consider. Even with coverage under Part D plans, some beneficiaries may face out-of-pocket costs for the drug, which can be as high as $1,300 per month. KFF’s analysis indicates that beneficiaries who take Wegovy may still be required to pay a percentage of the drug’s list price for a month’s supply, resulting in monthly out-of-pocket costs ranging from $325 to $430.
Despite the potential benefits of Wegovy for eligible Medicare beneficiaries, there are challenges related to coverage and access. Some Part D plans may delay coverage of Wegovy until 2025, which could impact beneficiaries who are in need of the drug sooner. Additionally, the implementation of cost-control measures, such as step therapy requirements, by Part D plans could limit access to Wegovy for some beneficiaries. These requirements may mandate that plan members try lower-cost medications or weight loss methods before being approved for Wegovy, which could deter some beneficiaries from utilizing the drug.
Looking ahead, the coverage landscape for Wegovy among Medicare beneficiaries remains uncertain. While some Part D plans have announced their intention to cover Wegovy this year, the extent of coverage remains unclear. Many plans may be hesitant to expand coverage 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 among Medicare beneficiaries may not be realized until 2025, according to KFF.
While the approval of Wegovy for heart health represents a significant advancement in the treatment options available to Medicare beneficiaries, there are still challenges to navigate in terms of coverage and access. The financial implications of accessing Wegovy, the potential delays in coverage by certain Part D plans, and the implementation of cost-control measures all contribute to the complexity of the situation. Moving forward, it will be important for policymakers, insurers, and healthcare providers to work collaboratively to ensure that Medicare beneficiaries have timely access to Wegovy and other innovative treatments for obesity and related conditions.