Wegovy’s Medicare Part D coverage: Three pitfalls

Weight loss drugs have been all the craze recently. There are finally drugs that may help people drop pounds, and that is a superb thing. In recent years, the obesity rate amongst older adults within the United States has nearly doubled. Two out of 5 Americans age 65 and older are obese.

Wegovy is a medicine that a few of my clients would really like to take, but they quickly discover that it will not be covered by Medicare Part D drug plans. They don’t understand why they cannot get a medicine that may lower their risk for therefore many other health problems.

Three obstacles

There are requirements that plans must meet when determining which drugs can be included on their drug lists. These requirements can create barriers to coverage. Here are the three obstacles to Part D coverage from Wegovy and what, if anything, is being done to eliminate them.

1. Medicines can’t be excluded from insurance coverage.

The Social Security Act sets out the foundations for reimbursement of medication and excludes certain categories. One exception concerns medication for anorexia, weight gain or “Weight loss (even when not used for cosmetic purposes, e.g. in cases of morbid obesity).”

What is being done: In June, the House Budget Committee took a small step toward repealing this exemption. It voted The Obesity Treatment and Reduction Act of 2023 out of committee and into the House. This bill would allow Medicare to cover weight reduction drugs. But I would not put any money on this bill passing anytime soon. It has to pass the House and Senate and grow to be law by the tip of January or the method starts another time.

2. The drug should be approved by the FDA for its intended use.

This was the large stumbling block for Wegovy. In June 2021, the FDA approved it for weight reduction, an exception mentioned in the primary point.

What is being done: This ban has been lifted. 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 drug in its drug schedule.

When the drug was not approved for any purpose aside from weight reduction, it was not covered by medical insurance. But that has now modified.

What is being done: The FDA approval of Wegovy resulted in a memo from the Centers for Medicare and Medicaid Services. Because this drug was approved for a recognized medical indication, Part D plan sponsors can now add it to their drug lists and canopy the prices of 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 4 cities and located two Advantage plans, each sponsored by the identical insurance company in Wisconsin, that cover Wegovy today.

While I’m skeptical, I don’t imagine these numbers will increase within the near future for 2 reasons.

1. This will not be a trademarked drug.

Drug plans must cover all Antidepressants, immunosuppressants, anticonvulsants, antineoplastics, antiretrovirals, and antipsychotics. After that, plans must cover at the very least two drugs from the opposite classes. It’s very likely that every drug plan has already identified these two drugs in each class, so there is no have to add Wegovy from a compliance perspective.

2. This will not be an affordable medicine.

The list price is $1,349 monthlyor $16,188 per yr. Due to initiatives within the Inflation Reduction Act, drug plans cover a bigger share of the prices, from 15% to 60%, in accordance with KFFThose who took Wegovy this yr would likely go straight into catastrophic coverage, the phase wherein drug plans cover all costs. And next yr, they’d hit the $2,000 cap on Part D drugs in the primary few months.

There are already another medications that help with weight reduction.

• Zepbound received FDA approval for chronic weight management in adults with obesity, but will not be approved for a medical indication. Part D drug plans may not cover this medication.
• Ozempic, MounjaroAnd Rybelsus are all FDA-approved to enhance blood sugar control in adults with type 2 diabetes. The majority of individual and Medicare Advantage plans I reviewed cover these three drugs. The plans require prior authorization to verify that the person has diabetes and desires higher control. Once the drug is taken, weight reduction is an off-label profit.
• Currently, Wegovy is the one weight reduction drug approved for cardiovascular risks (heart attack, stroke and cardiovascular death). Perhaps this can be a reason for plans so as to add it to drug lists next yr.

Obese Medicare beneficiaries who would not have type 2 diabetes or cardiovascular risks must find other ways to drop pounds or pay for weight-loss medications out of their very own pocket.

What will 2025 bring?

The Medicare open enrollment period can be a time of discovery for a lot of with Part D coverage. Will we discover that the $2,000 cap makes highly helpful, high-cost drugs inexpensive for a lot of Medicare enrollees? Or will Part D drug plans adapt to the $2,000 cap by implementing more restrictions (prior authorization or step therapy) or selecting to not cover certain expensive drugs? Mark October 15 in your calendar and keep an in depth eye on what happens along with your plan.