Medicare weight-loss drug coverage could overwhelm doctors
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Next month's launch of a Medicare program providing weight-loss drugs for $50 a month is expected to unleash pent-up demand for Wegovy, Zepbound and other blockbuster treatments — and create new bottlenecks at doctors' offices.
The big picture: It could become one of the biggest drug rollouts ever — and it could test an already burdened system as seniors seek new GLP-1 prescriptions.
- Clinicians worry that could also give short shrift to patient counseling on how to take the injectables and pills, adjust dosages and deal with side effects.
- Medicare has been prohibited by law from covering weight-loss drugs.
Where it stands: The new program is part of a deal President Trump struck with Eli Lilly and Novo Nordisk to cut prices for their diabetes and anti-obesity drugs in exchange for access to more patients.
- Providers are bracing for an onslaught beginning July 1, with roughly 14 million Medicare beneficiaries overweight or obese, according to KFF.
- "I have a long list of people who are just holding their breath until July 1, who just could not afford the medication before," Christopher Weber, a board member of the Obesity Medicine Association, told Axios.
First, though, they'll have to go through a verification process, or "prior authorization," to determine whether they qualify for the low-cost drugs.
- "We're already in primary care and obesity medicine kind of overwhelmed with prior authorizations ... this is going to overwhelm a lot of clinics," Weber said.
Medicare administrators have told doctors they are streamlining the process and establishing a central clearinghouse for the reviews.
- "In our situation we would have to double or triple our pharmacy team, and to my knowledge, that has not happened in preparation for this," said Annie Moore, an internal medicine doctor at the University of Colorado.
- A Centers for Medicare and Medicaid Services spokesperson said the agency doesn't anticipate that the program will create any undue burden on pharmacies or prescribing providers.
Between the lines: The new program only runs through the end of 2027 and limits coverage to the weight-loss drugs.
- Medicare isn't paying for nutrition and behavioral support programs that often accompany employer-sponsored obesity treatment. That could be particularly concerning for older adults, who often require closer monitoring to avoid losing weight too quickly and becoming frail.
- "The primary care clinician can do the counseling, but most people aren't going to have time to give it adequate time," Weber said.
Friction point: Beneficiaries may get sticker shock when they discover the benefit does not count toward their out-of-pocket caps or deductibles, KFF's Juliette Cubanski told Axios.
- "I think it could be a bit of a rocky start as the program rolls out in July," she said.
- And at $50 a pop, these drugs may still be too expensive for many on fixed, low incomes.
- Uptake may also be limited because many seniors have already gotten a GLP-1 prescribed for another condition like sleep apnea or other indication through their Part D benefit. They won't qualify for this discount, even if they are overweight or obese.
What's ahead: Leading GLP-1 makers Novo Nordisk and Eli Lilly see a potential windfall opening up the market to Medicare patients and are targeting advertising at seniors, CNBC reported.
- Novo Nordisk plans to advertise the reduced risk of cardiovascular events like heart attack and stroke for its Wegovy and Ozempic while Lilly plans to pitch the convenience of its new GLP-1 pill Foundayo.
