The Trump administration has recently overturned a plan initiated by the Biden administration that aimed to allow Medicare and Medicaid to cover prescription medications for obesity, such as Wegovy. This prohibition on coverage has been in place for over 20 years, with the Biden administration proposing a rule in November 2024 to reinterpret existing regulations to allow for coverage under Medicare's Part D outpatient benefit. The plan would have also expanded Medicaid coverage, which currently only includes obesity medications in 13 states.
The Centers for Medicare and Medicaid Services (CMS) estimated that removing the ban could make approximately 7.4 million beneficiaries eligible for these medications, potentially costing Medicare $25 billion and Medicaid $11 billion over the next decade. However, these figures are lower than estimates from other sources, suggesting that the financial implications of this coverage change are complex and debated.
The future of the proposed rule remains uncertain. A spokesperson for CMS indicated that reconsideration may be possible, particularly if the costs of branded weight-loss drugs decrease. Currently, these medications, like Wegovy and Zepbound, have a list price exceeding $1,000 per month, although negotiated prices can be lower for certain health plans.
In Congress, the Treat and Reduce Obesity Act (TROA) aims to lift the Medicare ban on weight loss drug coverage but has faced challenges due to concerns over rising healthcare expenditures. Support for the bill has been bipartisan, yet it has not advanced to a vote.
With ongoing federal budget constraints, significant changes to obesity medication coverage in public programs appear unlikely in the near future, leaving many beneficiaries without access to these potentially beneficial treatments.