By Mariam Sunny and Sneha S K
July 1 (Reuters) – Millions of Americans are expected to gain coverage for GLP-1 drugs for weight loss under a new U.S. pilot launching on Wednesday in its Medicare program for people aged 65 and older or with disabilities that will offer the medications for a monthly co-pay of $50.
Eligible beneficiaries can obtain drugs including Novo Nordisk’s Wegovy in injection or pill form and Eli Lilly’s Zepbound four-dose KwikPen injection and Foundayo pill through the end of 2027. The program will not cover single-dose Zepbound vials or pens. Here are more details:
WHO IS ELIGIBLE?
Medicare participants who do not already qualify for GLP-1 drugs for other conditions such as type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease through their Medicare prescription drug coverage plans may be eligible.
They must fall into one of the following categories:
• A body mass index of 35 or above
• A BMI of 30 and above with heart failure, uncontrolled hypertension or certain severe chronic kidney diseases
• A BMI of 27 and above plus pre-diabetes, previous heart attack or stroke or symptomatic peripheral artery disease
A BMI of 25-29.9 is considered overweight, while a BMI of over 30 is classified as obese.
WHAT THEN?
If a patient is eligible, a doctor or healthcare provider must send a prescription for a covered GLP-1 drug to the pharmacy and complete a prior authorization. A provider must certify that the patient is using the GLP-1 drug as part of a lifestyle program that focuses on diet and exercise.
WHAT HEALTH CONCERNS DO DOCTORS HAVE?
Clinicians warn that older adults require careful management because the loss of lean muscle mass along with fat could potentially worsen age-related muscle loss and frailty. It may also affect the absorption and effectiveness of other medications.
Obesity specialists are advising patients to undertake resistance training and high-protein diets to help preserve lean mass during weight loss.
Doctors typically advise the intake of 1.2 to 1.6 grams of protein per kilogram of body weight daily to help preserve muscle mass during weight loss, said Dr. Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital.
Rapid weight loss can also reduce bone mineral density, a particular concern for postmenopausal women and older adults who already face an elevated risk of osteoporosis and fractures. To mitigate that risk, clinicians are incorporating baseline DEXA scans to assess bone health, monitoring bone density over time, and ensuring patients maintain adequate calcium and vitamin D intake.
“A concern is that access to the drug may expand faster than access to the clinical support needed to use it safely and effectively,” said Dr. John Batsis, a geriatric medicine specialist at University of North Carolina at Chapel Hill.
WHAT REMAINS UNCLEAR?
It is unclear if physicians and pharmacies will be prepared for the rollout, and whether Medicare will implement a new program after the demo ends in December 2027.
It is also unclear if it is sustainable. Medicare is paying about $250 per month, of which $50 is covered by the patient. That puts the costs of the program into the billions of dollars annually depending on how many millions of people sign up.
“In the short term, we have this program that will be helpful for people,” said Juliette Cubanski, program director on Medicare policy at KFF. But it “comes at a cost to the federal government and doesn’t really represent a sustainable approach to longer-term Medicare coverage of drugs used for weight loss.”
(Reporting by Mariam Sunny and Sneha S K in Bengaluru and Chris Prentice in New York; editing by Caroline Humer and Bill Berkrot)
