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Boxes for the medications Wegovy and Zepbound. File photo by JoNel Aleccia\/AP<\/p>\nBoxes for the medications Wegovy and Zepbound. File photo by JoNel Aleccia\/AP<\/p>\n
For many, drugs like Wegovy and Ozempic seem a miracle. But for those without the extra $300 to $1,200 it can cost to buy the drugs out-of-pocket, getting insurance coverage for the diabetes drugs, which are known to alleviate a slew of other weight-related health conditions, can prove a nightmare.<\/p>\n
The story is all too familiar to Dr. Michelle Dorwart, the president of the Vermont Academy of Family Physicians and a family doctor at a community health center in Burlington.<\/p>\n
\u201cIt\u2019s really tough. You are thinking, \u2018Wow, this could really be helpful for this person,\u2019\u201d she said, describing her work with patients who may benefit from the drugs, \u201cbut it\u2019s really hard to get covered.\u201d\u00a0<\/p>\n
Now, a new Medicare pilot program is offering a glimmer of hope for some Vermonters who have struggled to access the weight loss and diabetes medications.\u00a0<\/p>\n
The drugs, called GLP-1s, work by mimicking a natural hormone that regulates the amount of sugar in blood, which in turn slows down digestion and makes the brain feel more satiated.\u00a0They originally were approved for managing diabetes but have increasingly been found to work for weight loss, too.\u00a0<\/p>\n
Up until July 1, a Medicare patient could not get insurance coverage for a GLP-1 for weight loss specifically, according to Natalie Powers, a pharmacist and the director of clinical programs at Kinney Drugs.<\/p>\n
The nationwide Medicare GLP-1 Bridge<\/a> program allows Medicare beneficiaries with drug coverage to access one of three different weight loss GLP-1 drugs if the beneficiaries meet a set of broadened\u00a0criteria. Medicare is the federal healthcare program for those 65 and above or those with certain chronic illnesses. Under the new pilot, the drugs cost patients $50 a month.\u00a0<\/p>\n The program began July 1 and is set to run as a pilot through the end of 2027.\u00a0<\/p>\n Given how new the pilot is, it\u2019s hard to know exactly how many Vermonters have taken advantage of it \u2014\u00a0of the more than 170,000 Medicare eligible Vermonters, about 140,000 could qualify for the pilot with their drug coverage. But clinicians are optimistic that they will now be able to write prescriptions for patients who previously could not get the weight loss drugs covered by insurance.\u00a0<\/p>\n Dorwart shared the story of one patient with fatty liver disease who couldn\u2019t get insurance coverage for GLP-1 drugs \u2014 the drugs only have FDA approval to treat \u201cmoderate-to-advanced\u201d<\/a> manifestations of the disease.\u00a0<\/p>\n She made multiple calls trying to help the patient get coverage; she did an ultrasound that showed some build up of dangerous scar tissue, but not enough that it was severe enough for coverage \u2014 \u201cWhich is just crazy, right?\u201d Dorwart said.\u00a0<\/p>\n The best thing to do was to send the patient home and \u201cwait until her liver disease gets worse,\u201d Dorwart said.\u00a0<\/p>\n It\u2019s a situation that\u2019s often familiar for those who are prediabetic, have sleep apnea or other weight-related health conditions that the drugs aren\u2019t yet approved to treat.<\/p>\n \u201cThere are people who are kind of almost hoping that they\u2019ll have diabetes,\u201d Dorwart said. \u201cIt is a hard place to be because they want to be healthier and prevent complications from their diseases and they can\u2019t. They can\u2019t use this tool to do that.\u201d<\/p>\n Now, any Medicare patient with a body mass index of 35 and above is eligible for the drugs \u2014\u00a0a BMI of 30 or above is considered obese<\/a>. Those with lower BMIs who have heart failure, uncontrolled hypertension or chronic kidney disease are also eligible. So are those who are prediabetic, have had a stroke or a heart attack or have artery disease in their limbs.\u00a0<\/p>\n