Weight-loss drugs have been all the news recently. There are finally medications that can help people lose weight and that is a good thing. In recent years, obesity rates have nearly doubled among older adults in the U.S. Two of every five Americans ages 65 and older are obese.
Wegovy is one drug that some of my clients would like to take. However, they quickly discover that Medicare Part D drug plans do not cover it. They do not understand why they can’t get a medication that can lower their risk for so many other health problems.
Three Stumbling Blocks
There are requirements that plans must meet when determining which medications to list in their formularies. Those requirements can create impediments to coverage. Here are the three stumbling blocks to Part D coverage of Wegovy and what, if anything, is being done to remove them.
1. The drugs cannot be excluded from coverage.
The Social Security Act spells out the rules for coverage of medications and excludes certain categories. One exclusion is drugs used for anorexia, weight gain, or “weight loss (even if used for a non-cosmetic purpose (i.e., morbid obesity).”
What is being done: In June, the House Ways and Means Committee took a baby step toward reversing this exclusion. It voted The Treat and Reduce Obesity Act of 2023 out of committee and into the full House. This act would allow Medicare to cover weight loss drugs. But I wouldn’t place any money on the chances that this act will go anywhere soon. It must pass the House and Senate, and be signed into law by the end of January or the process starts over.
2. The drug must be approved by the FDA for the specific purpose.
This has been the big stumbling block for Wegovy. In June 2021, the FDA approved it for weight loss, an exclusion noted in the first point.
What is being done: This block has been removed. In March 2024, the FDA approved Wegovy to “reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.”
3. A drug plan must list the medication in its formulary.
When the drug was not approved for a purpose other than weight loss, plans could not cover it. But now, that has changed.
What is being done: The FDA approval of Wegovy led to a memo from the Centers for Medicare and Medicaid Services. Because this drug has received approval for an accepted medical indication, Part D plan sponsors can add it to their formularies now and cover the medication.
Plans can cover this drug but will they? I just checked 83 stand-alone Part D drug plans and 235 Medicare Advantage plans in four cities and found two Advantage plans, both sponsored by the same Wisconsin insurance company, that cover Wegovy today.
Consider me skeptical but I don’t think those numbers are going to increase anytime soon for two reasons.
1. This is not a protected drug.
Drug plans must cover all antidepressants, immunosuppressants, anticonvulsants, antineoplastics, antiretrovirals, and antipsychotics. After that, plans must cover at least two drugs from the other classes. It’s very likely that every drug plan has already identified those two drugs in every class so it’s not necessary to add Wegovy from a compliance perspective.
2. This is not a cheap medication.
The list price is $1,349 a month, or $16,188 a year. Because of initiatives in the Inflation Reduction Act, drug plans are picking up a greater share of the costs, from 15% to 60%, according to KFF. Those who would take Wegovy this year would probably cruise right through to Catastrophic Coverage, the stage in which drug plans cover all the costs. And next year, they would reach the $2,000 cap on Part D drugs in the first few months.
There are some other drugs already available to help with weight loss.
- Zepbound received FDA-approval for chronic weight management in adults with obesity but has not been approved for a medical indication. Part D drug plans cannot cover this drug.
- Ozempic, Mounjaro, and Rybelsus are all FDA-approved to improve glycemic control in adults with Type 2 diabetes. The majority of standalone and Medicare Advantage plans I checked do cover these three drugs. Plans will require prior authorization to verify that the individual has diabetes and needs better control. Once on the medication, weight loss is an off-label benefit.
- At this time, Wegovy is the only weight-loss medication approved for cardiovascular risk (heart attack, stroke and cardiovascular death). Perhaps that may be a reason for plans to incorporate it into their formularies next year.
Obese Medicare beneficiaries who do not have Type 2 diabetes or cardiovascular risk will have to find other ways to lose weight or pay for weight-loss drugs out-of-pocket.
What Will 2025 Bring?
The Medicare Open Enrollment Period will be a time of discovery for many with Part D coverage. Will we find that the $2,000 cap brings highly beneficial, highly priced drugs within reach of many Medicare beneficiaries? Or will Part D drug plans adapt to the $2,000 limit by putting in place more restrictions (prior authorization or step therapy) or opting not to cover certain, costly drugs? Mark your calendar for October 15 and pay close attention to what’s happening with your plan.
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