Medicare and higher prices

[keangkong]

My understanding is that folks on Medicare have to pay a much higher cash price for tirzepatide and semaglutide than other folks whose insurance doesn't cover these drugs. Is that an intentional decision on the part of the manufacturers? Or is that mandated by U.S. law?

 

[m100568]

My understanding is that it is an old law prohibiting discounts on weight loss meds -- think Fen Fen. The law makes no sense for GLP-1s, but it is still the law. Good luck changing it. "Oh, so you want to make a common sense change to that law, well what I want in return is. . . . " You know how politics goes. In the meantime, how many people over 65 will be priced out of the market, or forced into grey?

 

[MsGizmo]

My understanding is that folks on Medicare have to pay a much higher cash price for tirzepatide and semaglutide than other folks whose insurance doesn't cover these drugs. Is that an intentional decision on the part of the manufacturers? Or is that mandated by U.S. law?

My mother gets her Ozempic from Medicare and I believe it costs her about $45 a month. She is a diabetic. I don't know what it would cost for Ozempic without insurance but I paid $499 out of pocket for Wegovy. (same drug, same dose, different name) Medicare doesn't usually cover weight loss drugs at all.

 

[Morbius]

Most people who aren't us seem to think that weight loss drugs are sketchier than getting a boob job.

 

[nonyabizznez]

Medicare recipients who aren't T2 diabetic pay full price for GLPs. Medicare recipients and the federally insured were/are exempt from coupons that kept people going in '23 and '24. Even with new indications gaining "approval" it doesn't matter if it's not on the formulary of your Plan D.

Medicare recipients who are T2 and covered pay about $45/mo until they hit the donut hole. The donut hole was larger in '24 than this year. The average monthly OOP accounting for the donut hole in '24 was about $160/mo. Ozempic/Mounjaro are tier 3.

Why? The Anti-Kickback Statute! Seriously!!

 

[GLP1Pharmacist]

Weight loss not covered, get prescription for diabetes drug if you can.

 

[byefatlicia]

Most people who aren't us seem to think that weight loss drugs are sketchier than getting a boob job.

I think you are right. People react weird when you bring it up...

Maybe I shouldn't be wearing a speedo yet LMAO

 

[Sunflower]

Medicare recipients who aren't T2 diabetic pay full price for GLPs. Medicare recipients and the federally insured were/are exempt from coupons that kept people going in '23 and '24. Even with new indications gaining "approval" it doesn't matter if it's not on the formulary of your Plan D.

Medicare recipients who are T2 and covered pay about $45/mo until they hit the donut hole. The donut hole was larger in '24 than this year. The average monthly OOP accounting for the donut hole in '24 was about $160/mo. Ozempic/Mounjaro are tier 3.

Why? The Anti-Kickback Statute! Seriously!!

Sounds accurate. My T2D father on Medicare got Mounjaro for $30/month, but quit after 3 weeks due to reflux. No way would he let me microdose him on my bootleg Tirz, even though it’s even cheaper than $30/month. 🤷‍♀️

Scary thing for the people relying on insurance is not knowing when the coverage cuts off.

 

[Sunflower]

I think you are right. People react weird when you bring it up...

Maybe I shouldn't be wearing a speedo yet LMAO

Boob jobs have been somewhat common and socially acceptable for a few decades. GLP1 meds have only become common the past few years, but will be more accepted by society quickly, as they are being used more than plastic surgery now.

Let’s hope speedos for dudes and topless rights for ladies are next up!

 

[keangkong]

My understanding is that folks on Medicare have to pay a much higher cash price for tirzepatide and semaglutide than other folks whose insurance doesn't cover these drugs. Is that an intentional decision on the part of the manufacturers? Or is that mandated by U.S. law?

It looks to me that federal law, consisting of both the United States Code and the Code of Federal Regulations, prohibits providing coupons for medication to those on Medicare. https://www.thehealthlawpulse.com/2014/09/drugmakers-liable-for-improper-copay-coupon-use-2/