Getting Wegovy Or Zepbound Through Medicare? Here's What Patients Need To Know Before Coverage Rolls Out Wednesday

Millions of Medicare beneficiaries will gain access to obesity drugs for the first time starting Wednesday under CMS’ temporary Bridge program, a federal initiative designed to expand GLP-1 obesity drug coverage for eligible seniors at a $50 monthly copay.

The program marks a major shift in Medicare coverage.

While Medicare Part D already covers some GLP-1 drugs for conditions such as diabetes and cardiovascular disease, federal rules had long blocked coverage for obesity treatment alone.

Bridge temporarily changes that through the end of 2027.

How Bridge Works The program is available to Medicare beneficiaries enrolled in Part D prescription drug plans.

Eligible patients include those with a body mass index (BMI) of 35 or higher, along with some patients with lower BMIs who also have obesity-related conditions such as prediabetes, prior stroke, heart attack or blocked arteries in the arms or legs.

Covered drugs include Wegovy injections and pill formulations, along with Zepbound in its KwikPen form.

The $50 monthly copay is significantly below current cash prices.

Out-of-pocket costs for GLP-1 treatments can range from roughly $199 to $699 per month, depending on the drug and dosage.

However, the copay does not count toward Medicare Part D deductibles or annual out-of-pocket spending caps.

More than 69 million Americans are enrolled in Medicare, and estimates from Novo Nordisk A/S’ (NYSE: NVO ) and Eli Lilly and Co. (NYSE: LLY ) suggest roughly 15 million to 20 million older adults may qualify for weight-loss treatment.

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To receive coverage, a healthcare provider must first write a prescription, triggering a prior authorization request.

The provider must then certify that the patient meets Bridge eligibility requirements.

CMS has contracted Humana Inc. (NYSE: HUM ) to process approvals and expects requests to be handled within 72 hours.

Even with that timeline, patients may face delays during the early rollout as clinics and pharmacies handle increased demand. "I do think we’re all going to have to be a little bit patient, because there is probably going to be a bit of a strain on clinics and pharmacies for the next couple of months," Carolynn Francavilla Brown, vice president of the Obesity Medicine Association, told CNBC.

Humana said it has 15 years of experience administering temporary Medicare drug coverage programs and expects to play a similar operational role for Bridge.

GLP-1 therapies have become one of pharma’s fastest-growing categories.

A Deloitte report released in May showed obesity drugs now account for 25% of late-stage pipeline sales forecasts, up from just 1% in 2022.

What Happens After 2027 Bridge currently runs only through Dec.

31, 2027, leaving uncertainty around future access. "It’s good news that Medicare is rolling out this program, but it is temporary, so it’s really not clear at this point what happens after the end of the 18-month program duration," Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, told CNBC.

Obesity specialists generally view GLP-1 treatments as ongoing therapies, and patients who stop treatment often regain weight.

A 2022 study found people who stopped Wegovy regained roughly two-thirds of prior weight loss within a year.

Disclaimer: This content was produced with the help of AI tools and was reviewed and published editors.

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