Medicare to cover obesity drugs for seniors starting July 1

Medicare will begin covering certain obesity drugs for eligible seniors on July 1 through a new Bridge demonstration program, giving some beneficiaries access to GLP-1 medications for a monthly copay of $50. The Centers for Medicare & Medicaid Services said the short-term program will run through December 31, 2027 and operate outside Medicare Part D’s usual coverage and payment flow.

CMS Administrator Dr. Mehmet Oz said the medicines are a major medical advancement, but too many seniors cannot get them. Chris Klomp, who oversees Medicare at the U.S. Department of Health and Human Services, said the demonstration is designed to make access simpler, more predictable and more consistent across Medicare.

Eligibility is narrow. CMS says beneficiaries generally must already be enrolled in Medicare Part D, must be taking a GLP-1 specifically to reduce excess body weight and maintain weight reduction, and must meet clinical criteria that include a body mass index of at least 35, or a BMI of at least 30 with heart failure with preserved ejection fraction, uncontrolled hypertension or chronic kidney disease stage 3a or above, or a BMI of at least 27 with pre-diabetes, a previous heart attack, a previous stroke or symptomatic peripheral artery disease. People already getting a GLP-1 through Part D are not eligible for the Bridge, and neither are people using the drugs for type 2 diabetes, moderate-to-severe sleep apnea or metabolic dysfunction-associated steatohepatitis, also called MASH or fatty liver disease, because those uses stay in the normal Part D pathway.

The coverage is expected to include the pill and injectable forms of Wegovy, the KwikPen version of Zepbound and the Foundayo pill. Cash prices for GLP-1 weight-loss drugs typically run from $149 to $699 a month even with discounts, creating a steep gap between list price and the new Medicare copay.

A late-March survey released in early June by the Obesity Care Advocacy Network found that 82% of older Americans were unaware Medicare was about to cover obesity drugs, including 79% of Republicans and 84% of Democrats. The late-March survey included more than 2,100 adults ages 65 and older. CMS said it is working with providers, pharmacies and manufacturers ahead of launch and will use centralized claims adjudication and pharmacy payment systems.