Boxes for the medications Wegovy and Zepbound. File photo by JoNel Aleccia/AP 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 a lleviate a slew of other weight-related health conditions, can prove a nightmare. 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. “It’s really tough. You are thinking, ‘Wow, this could really be helpful for this person,’” she said, describing her work with patients who may benefit from the drugs, “but it’s really hard to get covered.”  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.  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. They originally were approved for managing diabetes but have increasingly been found to work for weight loss, too.  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. The nationwide Medicare GLP-1 Bridge 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 criteria. 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.  The program began July 1 and is set to run as a pilot through the end of 2027.  Given how new the pilot is, it’s hard to know exactly how many Vermonters have taken advantage of it — of 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.  Dorwart shared the story of one patient with fatty liver disease who couldn’t get insurance coverage for GLP-1 drugs — the drugs only have FDA approval to treat “moderate-to-advanced” manifestations of the disease.  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 — “Which is just crazy, right?” Dorwart said.  The best thing to do was to send the patient home and “wait until her liver disease gets worse,” Dorwart said.  It’s a situation that’s often familiar for those who are prediabetic, have sleep apnea or other weight-related health conditions that the drugs aren’t yet approved to treat. “There are people who are kind of almost hoping that they’ll have diabetes,” Dorwart said. “It is a hard place to be because they want to be healthier and prevent complications from their diseases and they can’t. They can’t use this tool to do that.” Now, any Medicare patient with a body mass index of 35 and above is eligible for the drugs — a BMI of 30 or above is considered obese. 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.  About 30% of Vermonters 65 and older have a BMI of 30 or above, making Vermont one of the least obese states in the nation, according to a 2024 ranking by United Health Foundation. “We’re really excited that this is expanding care for these patients who really are going to find benefit from them,” Powers said.  She hopes that the 18-month pilot will yield enough evidence for the Centers for Medicare Medicaid Services and other insurers to see if increasing access to weight loss medication results in lower overall healthcare costs and better health outcomes.  “If you can decrease hospitalizations and long-term effects of having a heart attack, having a stroke, having uncontrolled hypertension that leads to chronic kidney disease, it’s going to save millions and millions of dollars in the healthcare system,” Powers said.  To Dorwart, the logic is obvious, too: “Ultimately, if you’re avoiding complications, you’re saving money,” she said.  But she added that the “greater benefit is to the individual, who’s having better health.” She warned against treating GLP-1s as a cure-all. Their use for weight loss and associated conditions is still so new that clinicians need to wait to see the long-term impacts, she said.  And in her practice, Dorwart sees more Medicaid than Medicare patients. That population — as well as those with private insurance — is still not included in the pilot program.  “Any effort to lower costs is great, and if it actually ends up helping people, then that was awesome,” she said. “I’m hopeful — cautiously optimistic.” Read the story on VTDigger here: For some patients seeking drugs like Ozempic, the best path is to just get sicker. ...read more read less