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You can’t turn on the TV and not hear about one weight loss drug or another. That has led to many people asking the question; what insurance covers Wegovy (GLP-1s)?

As of March 2024, the House Ways and Means Committee voted to pass the Treat and Reduce Obesity Act of 2024. This bill will allow Medicare Part D plans to cover GLP-1s (glucagon-like peptide agonists) to treat obesity when the enrollee is prescribed the drug before enrolling in Medicare. CMS approved Part D coverage of the weight loss drugs when prescribed for individuals with heart disease or strokes. The drugs are not approved for coverage when prescribed for weight loss alone.

Weight loss for prevention

The Ways and Means Committee suggested that covering drugs for weight loss alone makes sense as weight loss can prevent several illnesses triggered by obesity. By preventing obesity, medical treatment costs can be lower in the future.

It is a fact that obesity is a risk factor for several other medical conditions including diabetes, heart disease and even cancer. Many of these diseases are leading causes of mortality.

What is the cost of Obesity

It is estimated that obesity will cost the federal government over $4 trillion in the next 10 years due to rising healthcare costs for overweight Americans.

If this legislation does not pass, millions of people who are enrolling in Medicare lose coverage for potentially life-saving medications. These drugs have given many people back their lives and provided an opportunity for a healthier, active lifestyle.

If you need help enrolling in a Medicare plan; click here and learn why you should use a Medicare agent.

What if the legislation does pass

If the legislation passes and becomes a law, the already high demand for these drugs would grow even more. That in turn, could present greater supply issues than already exist. Manufacturers have imposed restrictions on off label use to try and deal with supply issues.

If this is legislation passes, the cost would be about $1.7 billion over the course of 10 years. This is the estimated cost only for drug coverage of those who had the prescription before they enrolled in Medicare. Some members want to be sure people do not lose this coverage just because they retire.

Future considerations

Some consider this bill as a step toward broader coverage. According to the Senate Health, Education, Labor and Pensions Committee, this could cause a significant impact on federal spending of about $400 billion annually if half of obese Americans took the drug.

Some committee members oppose the bill stating that; if even 10% of Medicare enrollees used the drug, it would cost approximately $27 billion each year. Although, other members would like to compel manufacturers to lower the cost of GLP-1s.

There are good arguments on both sides of this issue. We will all have to wait and see what happens next.

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Most Medicare agents have spent time explaining Medicare Part D deductibles to their clients. Many part D plans have a deductible. We will go over deductibles and how they impact the cost of your client’s prescription medications.

Medicare Part D

Part D (PDP) coverage is provided by private insurance companies that are approved by Medicare. Individuals enrolled in Medicare Part A and/or Part B who do not have other creditable coverage should enroll in a Part D plan. Even if the beneficiary does not currently take any prescription medications. Delaying part D enrollment for a period of 63 or more days causes the beneficiary to pay a late enrollment penalty.

If the beneficiary is Medicare eligible but has other creditable prescription coverage, they will not incur a penalty. The penalty lasts as long as the beneficiary has Part D coverage. Once a beneficiary is eligible for Medicare coverage, it is very important to enroll in a PDP plan.

Part D Deductibles

A deductible is the amount beneficiaries pay out-of-pocket for prescriptions before their Part D plan begins to share the costs. In other words, it is a threshold that is met before plan coverage kicks in. Once the enrollee pays the deductible, they generally pay a copay or coinsurance for prescription medications, with the PDP plan covering the remaining costs.

How Part D Deductibles Work

The specifics of Medicare Part D deductibles vary depending on the plan each individual chooses. Here are the key points clients should understand:

Annual Deductible

Most Part D plans have a deductible. The deductible is an annual amount, which can change each year. In 2024, the maximum deductible allowed by Medicare is $545. Some plans have lower deductibles, and a few may not even have a deductible at all. When this is the case, the coverage starts immediately.

Meeting the Deductible

The beneficiary must pay for the full cost of prescriptions until they pay the annual deductible amount. Once this threshold is met, the plan covers its portion of the prescription drug costs. The exact amount enrollees pay after meeting the deductible depends on each plan’s structure. Each plan has a specific co-pay or coinsurance amount depending on the plan’s formulary.

Formulary Tiers

Medicare Part D plans categorize drugs into different tiers. Each tier has a different cost associated with it, and generally, drugs on lower tiers (like generic medications) cost less than those on higher tiers (like brand-name or specialty drugs). The deductible may apply differently depending on the tier, and some plans might waive the deductible for drugs in certain tiers (usually tier 1 and sometimes tier 2 as well).

Changes in Part D coverage

It’s important to review PDP plan options each year during the Medicare Open Enrollment Period (October 15 to December 7). PDP plans can change their deductibles, drug formularies, and coverage, therefore it is imperative to ensure your client’s plan still meets their needs.

How deductibles impact plan cost

The deductible is one part of the overall cost of any Medicare Part D plan. Here are the ways it can impact the enrollees’ expenses:

Higher Deductibles

In most cases, plans with higher deductibles have lower monthly premiums. These plans may be a good choice for individuals who do not have prescription medications of whose medications are inexpensive (tier 1 or 2).

Lower Deductibles

Generally, plans with a low or no deductible have higher premiums. These plans can actually be more cost-effective for enrollees who require regular, expensive medications.

Managing the deductible

1. Compare plans: Our agents should use either Connecture or Sunfire to enter the client’s medication information and compare the costs of the Part D plans that are avialable. There are several things that contribute to the plan costs; deductibles, premiums, copays and coinsurance for each specific medication. Click here to watch a Sunfire demo on our YouTube channel.
2. Review all medications: Check the client’s current medications are covered by the plan’s formulary and what tier they are on. This can significantly affect out-of-pocket costs.
3. Apply for Extra Help: If the beneficiary has limited income and resources, they may qualify for Extra Help. This is also referred to as a Low-Income Subsidy, which helps pay for Medicare Part D premiums, deductibles, and co-pays.

Understanding Medicare Part D deductibles is an important part of managing prescription drug costs effectively. Agents should explain this to every PDP client and help them choose a plan that fits their healthcare coverage needs as well as their budget. An annual review of plan coverage allows clients to make any neccessary adjustments to their coverage and optimize coverage and minimize costs.

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