Obtaining potent weight-loss medications such as Ozempic and Wegovy can indeed present challenges for elderly Americans.
This is because a provision from 2003 prohibits Medicare, a federal health insurance program for people 65 and over, from paying for medications used to lose weight.
Medicare Prohibited from Paying for Weight-Loss Drugs
Without insurance, the cost of the medications might exceed $1,000 per month, making them unaffordable.
Drugmakers and other organizations are making a significant effort to convince Medicare to cover the cost of the medications, but the program’s prospective enormous expenditures remain a major roadblock.
Based to one analysis conducted in March by Vanderbilt University researchers, if only 10% of Medicare patients received Wegovy treatment, the program would incur annual costs of $26.8 billion and prescription plan premiums would rise.
However, should these GLP-1 medications prove successful in aiding patients in managing or preventing other expensive chronic conditions like diabetes or heart disease or in helping them lose weight, the savings in overall healthcare costs may partially offset the additional costs, according to the KFF analysts
Medicare sets the standard for coverage decisions, and the private sector frequently imitates it.
The new price-negotiation capabilities granted to Medicare by the Inflation Reduction Act are an intriguing twist that could emerge in this discussion.
Based on the medicines’ 2017 Food and Drug Administration approval date, semaglutide would have a negotiated price no earlier than 2027 if they were added to the constrained list of negotiated pharmaceuticals.
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Policies for Affordable Access
These items are made more inexpensive for patients by the IRA’s $2,000 annual cap on out-of-pocket expenses, according to the analysts, although access issues could still arise.
They suggested that policymakers may modify Part D to increase the affordability and accessibility of these medications.
The Treat and Reduce Obesity Act, the main legislation that would do this, has been stalled in Congress for more than ten years. Since its previous introduction in 2021, it hasn’t been brought up in the current Congress.
Despite this, some supporters of the measure are optimistic about its prospects because it now has 176 cosponsors after growing in popularity over time.
The pharmaceutical industry, including Novo Nordisk and Eli Lilly, other healthcare organizations, and patient advocacy groups are urging Congress to act.
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