The recent approval of Wegovy for heart health in the U.S. has opened up coverage opportunities for more than 3 million people with Medicare, according to a recent analysis from KFF. This means that beneficiaries who are obese or overweight, have a history of heart disease, and are specifically prescribed the weekly injection to reduce their risk of heart attacks and strokes can now access this breakthrough weight loss drug through their Medicare Part D plans.
While the approval of Wegovy may provide much-needed relief for some Medicare beneficiaries, there could be potential financial strain on the program due to the high cost of the drug. KFF estimates that Medicare's prescription drug plans could spend an additional net $2.8 billion if just 10% of the eligible population uses Wegovy for a full year. This could lead to challenges in budgeting and allocation of resources within the Medicare program.
Despite the coverage options available for Wegovy under Medicare Part D plans, some beneficiaries may still face out-of-pocket costs for the drug. KFF's analysis found that those who take Wegovy could potentially incur monthly out-of-pocket costs ranging from $325 to $430. While a new Part D cap on out-of-pocket spending aims to limit these costs, they may still be a significant burden for individuals with modest incomes.
In addition to financial concerns, Medicare beneficiaries who wish to access Wegovy may also face challenges related to drug coverage requirements. Some Part D plans may implement restrictions such as step therapy, which could hinder access to the drug for certain individuals. The uncertainty surrounding the widespread coverage of Wegovy under Medicare Part D plans raises questions about the accessibility of the drug for eligible beneficiaries.
Looking ahead, it remains to be seen how Medicare Part D plans will navigate the coverage of Wegovy in the coming years. While some plans have already announced their intentions to cover the drug, others may be hesitant to expand coverage due to financial constraints. However, the potential for broader coverage in 2025 suggests that more beneficiaries may have access to Wegovy in the future.
The approval of Wegovy for heart health under Medicare has the potential to benefit millions of eligible beneficiaries. However, challenges such as out-of-pocket costs, coverage restrictions, and budgetary implications may impact the accessibility of the drug for some individuals. It will be crucial for Medicare to continue monitoring the impact of Wegovy coverage on its beneficiaries and address any barriers to access in order to ensure equitable healthcare for all.