r/Semaglutide • u/Sea_shell2580 • 1d ago
Trump Administration Drops Efforts to Provide Medicare coverage for GLP1s for obesity
[removed]
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u/Zealousideal_Pay6444 23h ago
This is very sad. A tremendous deal could have been made by asking Novo & LLY to significantly lower prices for guaranteed orders. A lot of people would benefit and it is becoming clearer each that GLP-1s can help in other areas of health. This could have been a great victory of the DJT administration.
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u/Cucurbita_pepo1031 23h ago
Theres no reason it is that expensive here, other than just pure greed. My endocrine disorder doesnt care what I eat, it still won’t use insulin the way it should. Semaglutide is the only medication that worked, and there isn’t a "better option" than glp1‘s. Phentermine is an Amphetamine. Orlistat makes you shit grease. Metformin is brutal for nausea and vomiting. If you’re like me, taking this med requires constant hoop jumping with insurance to get a prior authorization, and then paying for it is a massive hardship. My insurance covered it until I lost enough weight to not be pre diabetic and now they won’t cover it.
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u/amethystleo815 23h ago
It is a victory for the pharmaceutical companies. The only crowd DJT cares about is the CEOs
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u/memorablenuts 21h ago
If that were true, he wouldn’t be going to war with them. Have you seen the Dow?
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u/SnPlifeForMe 21h ago
Hey buddy... Just come back to this comment a couple years from now if you haven't choked from how deep you're throating him and Elon. 😂
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u/marcosalbert 21h ago
He didn’t go to war against pharma. The Dow is being slammed because of his indiscriminate tariffs on everything, which will tank the global economy.
That’s not to say that RFK doesn’t have his own agenda, but the Dow has nothing to do with that. And we still don’t know what’ll happen when Pharma CEOs and their checkbooks come butter Trump up when RFK does pull the trigger on whatever he has planned.
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u/GlizzyGobbler2023 14h ago
Yeah destroying the economy is great for us! We don’t need a 401k! Tariffs will somehow pay for our retirement.
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u/Angel061803 13h ago
No matter how much damage he does, there are still clueless people out there defending him. 🙄
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u/Comfortable-Rip-2050 23h ago
As a result of contracts with the government, those on Medicare will have to pay $1,300 a month, as opposed to the $499 Novo will charge others.
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u/Hefty_Somewhere_6267 14h ago
Just because Medicare isn't doing this doesn't mean private health insurance companies can't do it. I'm counting down the days until they figure it out and the light bulb goes off over their heads.
If I was Humana (for example), I'd give all Humana client access to GLP1s for free. Think of the overall savings and increase in profit if the entire cohort of insured individuals weren't overweight...
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u/Sufficient_Beach_445 10h ago
If they thought they would save money they would have done it by now.
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u/CaptainKermit1980 22h ago
If you’re Medicare and have the means to pay cash not using your Medicare benefits, you can fill Wegovy through NovoCare pharmacy for $499 a month
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u/Retired_At-Last 18h ago
I think that may have been the case but they have revised their language: Patient is not eligible if he/she is enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a government program), or where prohibited by law. Patients enrolled in a federal or state health care program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient. But I will still call to confirm. Zepbound at least doesn't have that restriction and maybe it will work for me, at least as long term solution - and maybe help me to lose the last 25 pounds I want to lose (lost over 70 on Ozempic).
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u/CaptainKermit1980 8h ago
That language is only for someone is trying active a copay card and fill locally. There is no activation of a through NovoCare pharmacy. I called verified on Wednesday afternoon. They said we now welcome Medicare through NovoCare pharmacy. It is kind of confusing.
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u/Retired_At-Last 4h ago
That is so great to hear and it's why I am calling them on Monday. Thank you!
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u/Retired_At-Last 22h ago
Curious how exactly you can do that. Do simply say you are not using Medicare? LLY doesn’t have that restriction so I plan to use tirzepatide but I don’t think it will work as well as semaglutide has worked. So any information you can share would be appreciated
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u/SnooEpiphanies1813 22h ago
You can buy any drug without insurance coverage if you choose to. So just pay for it yourself instead of supplying your Medicare information for payment.
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u/Retired_At-Last 20h ago
Thanks, very true - the difference in this instance though is the price. With the NovoCare offer it's $499. Otherwise, paying for it out of pocket it's over $1000.
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u/SnooEpiphanies1813 20h ago
Yes but why does that matter? NovoCare is just like buying direct, isn’t it? You should be able to buy without insurance same as at a retail pharmacy.
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u/Retired_At-Last 18h ago
That is what I am trying to sort out. There's is a special program for people who don't have coverage so it has some limitations. I just know if I try to get the drug from my local CVS since it isn't covered by my insurance it's $1000. I've read a lot and am still confused :)
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u/Retired_At-Last 18h ago
This is why I don't think I will be able to use NovoCare but I plan to confirm that: Patient is not eligible if he/she is enrolled in any federal or state health care program with prescription drug coverage, such as Medicaid, Medicare, Medigap, VA, DOD, TRICARE, or any similar federal or state health care program (each a government program), or where prohibited by law. Patients enrolled in a federal or state health care program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient.
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u/CaptainKermit1980 21h ago
That is correct, call 1‑888‑809‑3942 and NovoCare pharmacy will tell you the same thing
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u/Retired_At-Last 21h ago
Thank you. I will do that. I called once and they told me medicare was a no go, but I didn't think to say I would be paying cash. I hope it works. I was just getting ready to have my PCP write the prescription to Lilly.
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u/ExplanationFuture422 23h ago
I doubt that Trump even knows that it was dropped. Trump ,other than being an obnoxious loudmouth, is totally removed from anything having to do with running the Government.... well, other than appointing morons. This has RFK and Dr. Oz's fingerprints all over it.
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u/mimosameltdown 21h ago
He knows. He just wants to undo anything Biden did as revenge he doesn’t care who it hurts.
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u/Muffie-Face 11h ago
Lame. This will not be helpful with either access or the general public opinion. GLP 1s help with seizures which is huge for epilepsy. I hope that it gets more research and approval in general. People aren’t always kind about this for some reason. If it’s taken to help manage weight then it’s “lazy” not thre real way lol and talk all this bs. But it’s potentially a cure for many things and it’s still being hated on. I don’t get it. You know how much I’d prefer a shot over these seizure meds? A lot.
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u/Little_Sun4632 23h ago
It’s a sad state of affairs that taking a GLP1 in order to lower grocery bills.
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u/TheBetawave 23h ago
That's very sad. You can at least use the wegovy savings card to get a monthly dose for $499.
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u/Comfortable-Rip-2050 23h ago
Not if you’re on Medicare or Medicaid. It’ll cost me the full $1,300 a month if I continue my treatment. You can read these exclusions on the Wegovy website. My doctor said it has to do with the contracts pharmaceutical companies have with the government agencies.
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u/ATouchOfTheDizzies 22h ago
All government payers are excluded from drug savings programs, even DOD Tricare and it’s actually due to federal anti-kickback statutes that prohibit the offering of anything of value (cost savings) to get people to buy things that are reimbursable by the government.
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u/SamuraiRetainer 23h ago
And yet those male losers who voted for Trump still think he will do any good for them?
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u/Fun-Initiative-7044 10h ago
They don’t want Americans to be healthy, this has always been obvious.
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u/laura031619 13h ago
This isn’t about targeting people for punishment, it’s about financial burdens that the country cannot afford. The government represents everyone, not just some.
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u/CausticOptimism 11h ago
People deserve healthcare and these people will need less healthcare down the line as obesity has a number of comorbidities. Them being sick will potentially reduce their productivity or keep them out of the workforce entirely. No, this is entirely about who deserves to live or not since people not on these programs could potentially afford live saving medicine on their own.
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u/laura031619 11h ago
If people "deserve" healthcare, then why do we all have to pay for it? Why are doctors, pharmaceutical companies, and hospitals allowed to charge exorbitant prices for services that are essential to save lives? As much as it saddens me to say it, healthcare is not a right. This truth is hard to swallow, and it certainly causes some to feel disappointment and frustration. If you want to be mad at someone, channel your anger at the people setting the prices so high that they would bankrupt our country to be added to the Medicare Drug Schedule. Their greed is the problem, nothing else, especially since the exact same medicine is offered in Europe for a fraction of what they charge in the United States.
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u/CausticOptimism 8h ago
I don’t know how to convince you to care about the welfare of other people regardless of how useful or productive you think they are. I hope you’re never in a situation beyond your control.
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u/Grand-Information942 10h ago
Thank you for responding with logic and reason. Unfortunately, there is only so much money our government has to spend and there have to be priorities.
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u/Recipe_Limp 12h ago
🤦♂️🤦♂️🤦♂️Here are the facts “Medicare does cover GLP-1 drugs when prescribed for conditions like diabetes and heart disease, but legislation from 2003 prohibits Medicare from covering drugs for weight loss. There is a bipartisan push in Congress to allow for anti-obesity drugs and services to be covered through a bill called the Treat and Reduce Obesity Act (TROA), but it failed to advance in the last Congress.”
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u/Sea_shell2580 11h ago
Correct. And what I posted is also true -- that there was a Biden Administration effort which started in Nov 2024 to overturn the 2003 law via a CMS rule change to do the same thing that TROA would, that is, provide Medicare GLP1 coverage for obesity. But the Trump Administration has just decided to put a halt to that rule change effort. And since TROA has sat in Congress for 10 years and never moved, the tea leaves are clear that the Trump Administration will not be extending GLP1 Medicare coverage for obesity. He also selected an HHS secretary who is against GLP1s.
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u/Recipe_Limp 11h ago
Ok….never said it wasn’t. 🤷♂️🤷♂️🤦♂️🤦♂️ At this point, it’s like yelling at the scoreboard and thinking it will somehow make an impact.
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u/Local_Ad9906 15h ago
Politics. Really?
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u/Sea_shell2580 14h ago edited 14h ago
Not politics, policy. Like it or not, health care is regulated by the government. And government policy decisions like this not only impact Medicare, but they also impact commercial insurance coverage, as they tend to follow Medicare. These decisions don't happen in a vacuum. And yes, policy is driven by the leaders we put in office, so who is in office matters. We should all be connecting these dots and using them to inform our decisions, and our calls to our leaders, no matter what side we're on. Being informed is vital.
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u/Recipe_Limp 12h ago
Let’s take a look at the facts…Clearly, TDS it’s still a significant thing lol “Medicare does cover GLP-1 drugs when prescribed for conditions like diabetes and heart disease, but legislation from 2003 prohibits Medicare from covering drugs for weight loss. There is a bipartisan push in Congress to allow for anti-obesity drugs and services to be covered through a bill called the Treat and Reduce Obesity Act (TROA), but it failed to advance in the last Congress.”
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u/Sea_shell2580 12h ago edited 11h ago
TROA has sat in Congress for 10 years. It would grant Medicare coverage for the obesity indication. Congress ain't coming to save us anytime soon on that one.
My guess is the Biden Administration knew that and thus tried to pursue the CMS rule change to get GLP1 obesity coverage. You're correct that coverage still exists for the other indications, like diabetes. But getting obesity coverage is critical, because 42% of Americans are obese.
My point is the administration's abandonment of this proposal is a SIGNIFICANT setback. I doubt we will see any more movement on Medicare GLP1 coverage for obesity until we have a new Administration. That's not a political rant. That's reality.
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u/Recipe_Limp 12h ago
The Biden administration knew exactly what they were doing by suggesting the change right before he left office. They knew they were going to lose and wanted to make sure they had ammunition to try and reinvigorate their base after stepping on their own cranks by putting Kamala up as the candidate. They’re taking advantage of the emotional reaction aspect and the lack of real understanding from their base.
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u/Sea_shell2580 11h ago
Not true. The Biden Administration introduced the rule after the election, on 11/26/25. It was to be finalized in January 2025 right after the inauguration. It wasn't a last ditch attempt for votes.
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u/Recipe_Limp 11h ago
I agree 200%. They took advantage of the emotional aspect and set the table for what they already knew the outcome would be.
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u/_meaty_ochre_ 1d ago
Unfortunately unless the plan included finding a way to acquire it at non-insane prices, this is probably for the best.
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u/ExplanationFuture422 1d ago
Medicare would negotiate a price, just like they do for other drugs. It would be far less expensive that the current price in the united states.
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u/SuicidalDaniel4Life 23h ago
Time to go grey then. When I bought in bulk last Black Friday, I've paid €80 per 5 mg. It's your only way to protest extortion prices.
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u/Comfortable-Rip-2050 23h ago
Instead, those of us on Medicare will have to pay $1,300 monthly while the cost for others has gone down to $499.
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u/ATouchOfTheDizzies 21h ago
You could still go the Novo Nordisk direct to consumer route as a cash paying customer. No need for Medicare to be involved if you’re paying out of pocket.
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u/Comfortable-Rip-2050 20h ago
No, I can’t. Look at the Wegovy website where it states that anyone on Medicare must pay full price.
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u/ATouchOfTheDizzies 11h ago
You have to go to the NovoCare website. I took the time to look up the terms and conditions of the program for you:
“Eligibility and Restrictions
In order to participate in this program, patient must have a valid prescription for the brand being filled. A valid Prescriber ID# is required on the prescription.
Patients may participate in this program if they are uninsured or have insurance that does not cover obesity medicines. If the patient has insurance and fulfills their prescription through this program, the transaction will process outside of any insurance. Patient payments will not count toward any deductibles and cannot be applied to a patient’s maximum out-of-pocket costs.
By using this program, patients certify that he/she meets the eligibility criteria and will comply with the terms and conditions described herein and will not seek reimbursement for any medication received through this program.”
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u/EagleEyezzzzz 23h ago
Same as any other insurance, they negotiate the price down like 50-90%. Now people would have to pay out of pocket, and obviously they can’t. So they’ll just die of diabetes and heart disease (more expensive for the insurance) instead of actually getting effective treatment.
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u/Decent-Morning7493 23h ago
Paying for the medical costs of health issues by continuing to carry around the weight is greater than the cost of the drug. This has long been established.
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u/diablodeldragoon 1d ago edited 23h ago
The manufacturer already reduced the price in America by 60%
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u/Comfortable-Rip-2050 23h ago
Not if you’re on Medicare. For us it’ll be $1,300 a month. See the Wegovy website.
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u/diablodeldragoon 23h ago
That's because until they allow coverage under Medicare, they can't negotiate pricing.
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u/Comfortable-Rip-2050 23h ago
And it doesn’t look like it will be covered anytime soon.
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u/diablodeldragoon 22h ago
I mean, the secretary of health and human services seems to think the cure for everything is eating greens and avoiding sugar. I can't imagine we're going to get access to anything more advanced than leaches for the next 4 years.
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u/anonymowses 23h ago
Isn't that only through Lilly Direct? I don't see any changes at pharmacies.
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u/Flying-Tilt 1d ago
This is a good thing. After Medicare, it would go to Medicaid, and then 55 million overweight people on Medicaid would be allowed to get $1,700/month injections costing over 1 Trillion Dollars.
Kennedy talks about why we can't just give people vouchers to buy healthy food and education instead.
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u/jessbyrne727 23h ago
If it was so simple as eating healthy, why hasn’t everyone, including you, just done that?
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u/Flying-Tilt 23h ago
I was taught at a young age that I should follow the food pyramid. I was further educated that soda was good for me to drink every day. Mountain Dew day was a thing at my schools where they would just ship it in and give it away. It's hard to break these kinds of habits. I would like to see education changed to promote healthy eating. We know how bad most of this stuff is, but it's hard to fix it when billions of dollars are spent against us.
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u/jessbyrne727 23h ago edited 18h ago
But as an adult you have access to the information, so why haven’t you utilized it and built healthy habits? I was raised in an upper middle class family with healthy, home cooked meals and an active lifestyle. Despite being taken to nutritionists at an early age, guess who still battled with obesity my entire life?
The reality is there are far more factors at play, including genetics, hormones, and other underlying health conditions. Willpower alone isn’t effective for the majority of people, and the fact is that preventative healthcare results in lower overall costs in the long term.
And if this disordered eating is so ingrained in you- to the point where meal vouchers and education are not an effective treatment- why are YOU deserving of “a quick fix” but the poor, elderly, disabled and uninsured aren’t? A little hypocritical, no?
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u/pantema 23h ago
This is a very narrow perspective. Obesity causes a lot of very expensive health problems that are paid for by Medicare/Medicaid too.
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u/Flying-Tilt 23h ago
Yes, you are correct. I think we should focus on something that is a long term solution, and not a quick fix. How many posts have you seen on this sub about people who took the shot, ate like crap, and then were vomiting and/or shitting themselves the next day.
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u/pantema 23h ago
No, my point is that people who take GLP-1s and lose weight may save these programs on the cost of care for other medical issues caused by obesity
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u/Flying-Tilt 23h ago
I don't believe they can if they cost $1,700/month per person. I think there are cheaper alternatives.
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u/Cucurbita_pepo1031 23h ago
The point is literally that the price is inflated to make it inaccessible. It is not this expensive globally, just for Americans.
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u/Flying-Tilt 23h ago
I agree with you. It should not be this expensive. It should especially not be this expensive if our government is buying it in bulk 55 million doses.
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u/EagleEyezzzzz 23h ago
You think heart disease and diabetes, and alllllll their effects/surgeries/scans/drugs/specialists, don’t cost more than $1700 to treat on average? Lmaooooo.
My husband got a CAT scan a couple months ago and it was >$12,000 just for the scan itself. For 10 minutes in the machine. Not to mention billing for the specialist to analyze and report.
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u/Sea_shell2580 23h ago
Where are you getting $1700? You're right, there are cheaper alternatives. Novo is now offering Wegovy out of pocket for $500/month. Eli Lilly is offering Zepbound out of pocket, for $349 and $499/month, depending on dosage.
And truth is insurance plans never pay the list price for drugs, they pay a lower negotiated rate. So you can't look at a drug's list price and assume that's what Medicare would actually pay. It's more nuanced than that.
And last I checked, 11 or 12 state Medicaid programs already cover GLP1s.
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u/Flying-Tilt 23h ago
Do you really think that they would give the discount to Medicare/Medicaid? They would pay billions of dollars to lobby congress to make sure they get full price. Can you tell me what states have allowed this? This is the first I'm hearing about it. I would like to look into it more and see what they charge.
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u/Sea_shell2580 23h ago
Google is your friend. And yes, they would discount it.
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u/Flying-Tilt 23h ago
So the billions of dollars donated to your congressman wouldn't affect them in any way?
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u/Sea_shell2580 12h ago
Congress doesn't negotiate the prices of specific drugs. Congress wouldn't set pricing for Wegovy, that is CMS's job. Congress does have some influence on whether CMS has the authority to negotiate prices on any drugs, and CMS does the negotiations.
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u/TraditionalCatch3796 22h ago
Are you just here to be a troll? Have you looked at the sub you are in?
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u/SpicyArms 23h ago
The government would (or should) negotiate much lower rates for this and any medication.
BuY hEaLthY FoOd is not a solution and we shouldn’t listen to a guy with brain worms for any health advice.
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u/Flying-Tilt 23h ago
Yes, I agree, but there are laws in place so government is not allowed to negotiate much lower rates.
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u/cathie2284 20h ago
Why are you even in this sub? At 21 (now 53) was diagnosed with Graves' disease. Had to have my thyroid eradicated by radioactive iodine. I was allergic to the anti thyroid drugs that could have put the disease in remission. At the time, my thyroid was 97% over active.
Now- post menopause- I have tried to manage my weight and well, despite all efforts, it's become even harder. No working thyroid and all that comes from the wonderful "change of life." My body has continued to betray me. My metabolism just isn't what the normal person's is.
There are a myriad of issues out here where people struggle.
It isn't always about diet or exercise.
Take your food pyramid and find another sub. This isn't your place.
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