Medicare and Medicaid to Explore Coverage for GLP-1 Medications
The federal government may soon facilitate Medicare and Medicaid coverage for GLP-1 weight loss medications, such as Ozempic and Zepbound. An experimental program is reportedly in the works, as outlined in documents obtained by The Washington Post from the Centers for Medicare and Medicaid Services.
Details of the Proposed Experiment
This initiative would enable state Medicaid programs and Medicare Part D plans to provide coverage for medications specifically designed for “weight management” beginning next year. If successful, it could lead to broader accessibility of these high-cost, yet effective drugs.
Currently, Medicare does not cover any drugs for obesity treatment, including newer GLP-1 agents like semaglutide (found in Ozempic and Wegovy) and tirzepatide (Mounjaro and Zepbound). However, there is some leeway for coverage when these medications are used to treat diabetes or obesity-related conditions such as heart disease.
Previous Proposals and Current Developments
Last year, the Biden administration introduced a rule aimed at eliminating this restriction, which could expand coverage to approximately 7 million Americans by 2026. Although the Trump administration discarded this proposed rule earlier in April, Health Secretary Robert F. Kennedy Jr. indicated a willingness to explore a “framework” for expanding coverage.
The Role of the Center for Medicare and Medicaid Innovation
The Center for Medicare and Medicaid Innovation will oversee the experiment, which is tentatively set to last for at least five years. Medicaid coverage could become available in April 2026, while Medicare plans might follow in January 2027. Specific eligibility criteria are still being determined, with opportunities for public comment likely to shape the final plan.
Challenges and Expectations for GLP-1 Drugs
The latest GLP-1 medications like semaglutide have shown significant efficacy in weight loss compared to traditional methods like diet and exercise. However, their high costs and limited insurance coverage have made it difficult for many individuals to access or continue these treatments long-term. Some users experience gastrointestinal side effects that may limit their usage.
Encouragingly, the prices for medications such as Ozempic have begun to decrease. Canada is on track to approve its first generics of Ozempic early next year, although comparable options may not reach the U.S. market until 2030. The potential introduction of new competitors may further reduce prices in the near future.
