Is Medicare Covering Weight-Loss Drugs?

I’m currently being bombarded with questions about an announcement by the folks in Washington, D.C. who run Medicare that seniors will soon be able to purchase GLP-1 weight-loss drugs for $50 a month!

Let’s go ahead and address what we know about this right now. Of the people who have reached out to me so far with questions, none of them have understood how or if this is actually happening.

Time for some Straight Talk on this. It’s what I live for!

What We Know

First of all, this announcement has NOTHING TO DO WITH YOUR MEDICARE PLAN. Whether you are enrolled in a Medicare Part D drug plan or a Medicare Advantage plan that includes drug coverage, you will not get GLP-1 drugs covered through those plans.

What has been announced is a “workaround” to official drug coverage.

The U.S. Centers for Medicare & Medicaid Services (CMS) in Washington, D.C. are doing a few things to make a GLP-1 available to Medicare members for $50 a month.

They have negotiated with drug manufacturers and are going to buy GLP-1 drugs for weight-loss applications (think Zepbound® or Wegovy®) at a significant discount. Rumor has it the price will be around $245 a month, roughly half the price a non-Medicare beneficiary could buy the drugs for on a manufacturer’s website.

How It Will Work

CMS is creating a distribution channel, sort of a mini-Pharmacy Benefit Manager, to distribute the drugs OUTSIDE of original Medicare or Medicare insurance plans. There will be several requirements to get access to the drugs:

• You must be a Medicare enrollee with Part D or a Medicare Advantage plan that includes Part D coverage (even though you won’t be using your insurance to buy the drugs). People only on original Medicare, Parts A and B run by the federal government, will not qualify for the reduced prices.
• You must meet clinical criteria (typically a 30< BMI with no other health conditions or 27<BMI with certain health conditions).
• You must get a prescription from your doctor.
• Your doctor must submit prior authorization information to a centralized system that has not been created or turned on yet.

When you are able to access the drugs, it’s important to understand a few things:

• You are NOT going through your Medicare insurance or Part D drug plan to buy them. These purchases will not count toward any deductible or max-out-of-pocket computations.
• You are using a CMS-controlled access channel that handles prior authorization, processes claims and pays your pharmacy the balance of the cost of the drug. You are not using your insurance.
• The current program is a “short-term demonstration” funded through December 2027. We know nothing about what happens next.
• There are no subsidies for low-income folks in this program. The drug purchase is $50 a month for everyone who qualifies.
• It’s unclear at this time whether state-based extra charges, taxes and fees for prescription drugs will be required on these drugs.

The announcement says the availability will begin on July 1. No word on a website or system for healthcare providers and pharmacies being turned on just yet. But seniors being able to access weight-loss drugs for $50 is a huge deal.

The Straight Talk is, this is a huge opportunity for seniors who can’t afford to buy GLP-1 weight-loss drugs outright, and we’ll keep you advised as we hear more about how this program will work. Still curious? The CMS website has all of the official information on the program.