Does Medicare pay for GLP-1 medicine like Ozempic for weight reduction? For years, the reply has been a tough no. However a brand new “Bridge” program upgrades the reply to one thing extra like “sure, however …”
The brand new program’s greatest characteristic is pricing. Sure GLP-1 medicine will value simply $50 per 30 days. That’s a discount in comparison with Wegovy’s wholesale record value of $1,349.02. It even beats the most effective reductions out there on GoodRx or from the producer.
So what’s the catch?
There are a number of, truly. They usually’re vital — however if you happen to ask me, this system might be nonetheless value it.
The brand new program is known as the Medicare GLP-1 Bridge short-term demonstration. That “quick time period” is necessary: it lasts simply 18 months. This system begins July 1, 2026, and ends Dec. 31, 2027.
That’s not the way it was imagined to work.
The way it was imagined to work
Initially, the short-term program was meant to be a “bridge” to a longer-term answer. Subsequent would come the “Higher Approaches to Life-style and Vitamin for Complete hEalth” mannequin. (Some inventive authorities capitalization crams that title into the acronym “BALANCE.”)
Till the Steadiness mannequin went into impact, the Bridge program would’ve supplied early entry to $50 weight reduction medicine. Throughout its quick time period, the federal government could be on the hook for many of the invoice.
As soon as the Steadiness mannequin took impact, Medicare plans would pay for GLP-1s like different lined medicine. But when GLP-1 protection value greater than anticipated, the federal government would cowl a few of the further value.
The Steadiness mannequin was supposed to start out Jan. 1, 2027.
What’s occurring as a substitute
The Steadiness mannequin was voluntary and required a sure stage of trade assist. After the opt-in deadline for insurance coverage firms handed in April, the Facilities for Medicare & Medicaid Providers (CMS) introduced that it might delay the Medicare Steadiness mannequin.
There’s a silver lining to the delay. CMS prolonged the Bridge program, which might’ve wrapped up on the finish of 2026, via the tip of 2027. So if you wish to take benefit, you’ll have entry to $50 GLP-1s for the following 12 months and a half.
Examine Medicare Half D Plans
|
Insurance coverage firm |
NerdWallet score |
||
|---|---|---|---|
|
Greatest for low out-of-pocket prices
Humana |
Decrease than common |
3 (Common) |
|
Wellcare |
Varies |
3.5 (Above common) |
|
HealthSpring (previously Cigna) |
Common |
2 (Beneath common) |
|
UnitedHealthcare |
Common |
2.29 (Beneath common) |
It’s extra like a coupon than protection
GLP-1 medicine aren’t technically “lined” by Medicare beneath the Bridge program. It is a fiddly element, nevertheless it may actually matter for beneficiaries.
At $50 per 30 days, that’s as much as $600 per 12 months in further drug prices outdoors of your Medicare protection. The decrease costs may nonetheless be worthwhile, however that’s one thing to remember in your healthcare finances.
The longer term outlook is iffy
The Bridge program now ends Dec. 31, 2027.
Does it have a future? And what in regards to the Steadiness mannequin? In my opinion, the solutions rely on who — if anybody — is prepared to pay.
The Bridge program’s future
CMS may lengthen the Bridge program once more, in idea. However it might be expensive.
I requested CMS what the Bridge program will value taxpayers. Its spokesperson didn’t present that data.
That’s not going to cease this knowledge nerd. I took a take a look at what Medicare spends on the non-weight-loss variations of two Bridge program medicine: Wegovy and Zepbound. (The third, Foundayo, simply bought FDA approval in April, so it’s too new for spending knowledge.)
In 2024, Medicare spent over $19.3 billion on Ozempic and Mounjaro, based on gross spending knowledge from CMS. These are the non-weight-loss variations of Wegovy and Zepbound, respectively.
Amongst all lined medicine, Medicare spent the second-most on Ozempic. Mounjaro got here in fourth.
So even earlier than protecting GLP-1s for weight reduction, they’re costing Medicare a ton of cash.
There are about 14 million Medicare beneficiaries with weight problems, based on the Division of Well being and Human Providers. Persevering with to cowl weight reduction medicine for even a small portion of them may simply add billions per 12 months to an already strained finances.
I’d anticipate CMS to strive for a mannequin the place insurance coverage firms shoulder a minimum of a few of the value, as a substitute.
Will there be a Steadiness mannequin?
The price of protecting GLP-1s is probably going a priority for Medicare plans, too. Many insurance coverage firms are dropping non-Medicare protection for the medicine.
CMS didn’t formally state that not sufficient firms opted in for the Steadiness mannequin. A CMS spokesperson mentioned in an e mail that the delay was “to permit knowledge assortment that may assist a simpler potential implementation.”
Once I requested, CMS didn’t present particulars in regards to the future prospects for the Steadiness mannequin or the way it’s at present working with insurance coverage firms.
I additionally reached out for feedback on Bridge and Steadiness from lots of the largest Medicare firms. Those that bought again to me largely echoed CMS’ response.
A UnitedHealthcare spokesperson mentioned in an e mail that the corporate seems to be ahead to studying from the Bridge program and making use of insights to “a possible Steadiness program sooner or later.” Aetna, equally, praised the extension of the Bridge program and mentioned it might use program knowledge to plan for future GLP-1 protection.
Must you get GLP-1s via the Bridge program?
I can’t inform you whether or not GLP-1 weight reduction medicine are match for you medically. That’s a dialogue to have along with your physician.
However preserve the caveats in thoughts: The $50 price ticket wants to suit into your finances, separate out of your Half D protection. And this system most likely gained’t final perpetually, so that you would possibly must rethink that finances after 2027.
Full disclosure: I take Wegovy myself, although my medical insurance doesn’t cowl it. I get a fairly whole lot via my Costco pharmacy, however I nonetheless pay much more than $50 per 30 days. I don’t qualify for Medicare, but when I did, I’d take full benefit of the Bridge program’s low costs for so long as it lasts.
