A recent agreement between the Trump administration and drug manufacturers Eli Lilly and Novo Nordisk aims to lower the cost of obesity medications. However, the details reveal a complex system of pricing with varying costs depending on the drug, dosage, payment method, and insurance coverage. Here’s a breakdown of what this deal means for individuals considering or currently taking weight-loss medications.
Understanding the New Price Structure
The agreement introduces a tiered system of prices with potential savings, but significant differences based on specific circumstances.
- Lowest Prices Available: Two pills, orforglipron from Eli Lilly (starting dose) and a high-dose oral version of Novo Nordisk’s injectable Wegovy, will initially be offered at a monthly cost of $149. Eli Lilly has stated that higher doses of orforglipron will cost no more than $399 per month, although prices for higher doses of Novo Nordisk’s pill are yet to be announced.
- Current Medications (Wegovy & Zepbound): Individuals currently taking Wegovy can expect an average monthly price of $350, depending on the dose. Zepbound will be available for $299 for the lowest dose, reaching up to $449 for higher doses.
- Comparison to Existing Prices: These new prices are a reduction from current rates. Novo Nordisk currently offers Wegovy at $499 per month for patients paying out-of-pocket, while Eli Lilly previously charged $349 for its lowest dose and $499 for others.
Finding the New Prices and Accessing Them
- Direct-Sales Websites: The new prices will be accessible through direct-sales websites offered by Novo Nordisk and Eli Lilly.
- TrumpRx.gov: The Trump administration plans to launch a website, TrumpRx.gov, by the end of the year, which will link to these manufacturers’ websites.
Medicare Coverage Changes
A significant aspect of the deal is expanded Medicare coverage for obesity medications:
- Eligibility: Individuals with a body mass index (BMI) between 27 and 29 (overweight but not obese) who have prediabetes or established cardiovascular disease are now eligible. Those with a BMI in the low 30s (mild obesity) with conditions like uncontrolled hypertension, kidney disease, or heart failure also qualify. People with moderate or severe obesity (BMI over 35) are included.
- Cost for Eligible Patients: Medicare beneficiaries who qualify will have a monthly co-payment of no more than $50.
- Existing Coverage: A small portion of Medicare beneficiaries already had coverage due to existing obesity and related medical conditions.
Medicaid and Private Insurance
- Medicaid: Medicaid already covers Wegovy and Zepbound for patients with certain conditions like obesity and heart disease. State programs can decide on broader coverage for weight loss, with lower co-payments for those covered.
- Private Insurance: The impact on individuals with private insurance depends on their plan’s existing coverage. Those with coverage may not see immediate changes, while those without coverage may benefit from the lower direct-pay prices.
Important Details About Obesity Medications
- Administration: Patients typically administer these drugs via weekly injections, starting at a low dose and gradually increasing it under a doctor’s supervision.
- Weight Loss Process: Weight loss is gradual, with the starter dose typically not producing noticeable results on its own. Many patients don’t reach the highest doses due to cost or side effects.
- Clinical Trial Results: The health benefits, such as reduced risk of heart attacks, were observed in clinical trials using the highest doses.
In essence, this deal aims to make obesity medications more accessible, but navigating the new pricing structure requires understanding your insurance coverage, BMI, and any pre-existing health conditions.
