Who will pay for Trump program to have Medicare cover GLP-1s for obesity?

A new Medicare Part D and Medicaid pilot program, expected to begin in April 2026, would provide coverage for certain obesity drugs at a $50 copay for beneficiaries. However, many questions remain about how the program will operate and its implications for health plans.

The program would operate through the Center for Medicare and Medicaid Innovation (CMMI), which was authorized under the Affordable Care Act to develop and test new payment models. Currently, Medicare, by law, cannot cover drugs used solely for weight loss, but it does cover the glucagon-like peptide 1 (GLP-1) drugs when they are prescribed for diabetes and, under some circumstances, for sleep apnea.

The details of CMMI’s program for the obesity drugs have not yet been filled in. Until they are, Tracy Baroni Allmon, vice president of market access and health policy at Magnolia Market Access, says, “The big question is if patients are paying $50 and manufacturers have agreed to sell directly to cash-paying patients for $249, how much are the plans actually paying?”

That question stems from the large gap between the wholesale acquisition cost — effectively the list price — of the GLP-1 drugs that hover around $1,000 per month and the $50 per month that patients would pay. Without substantial manufacturer rebates to Medicare plans, the difference would be borne by the Part D plans and could, therefore, translate into dramatically higher premiums for all Part D beneficiaries, Allmon said.

The $50 copay limit for weight loss drugs for Medicare was mentioned in the Nov. 6 White House announcement about reduced prices for the GLP-1 drugs, which also highlighted lower prices through direct-to-consumer sales by the drugmaker.

Allmon noted that under former President Joseph Biden’s proposal to cover obesity drugs, Part D plans would have negotiated discounts of between 40% and 50% and charged patients between $200 and $300 per month. “Now, with mandated $50 cost sharing but no discussion of mandated rebates, plans could face substantially higher per-beneficiary costs,” she says.

A Congressional Budget Office report released in October 2024 showed that the direct costs for Medicare from covering obesity medications would increase federal spending by approximately $35 billion from 2026 to 2034, with only a small portion of that cost offset by savings from lower healthcare costs associated with obesity and obesity-related health conditions.

CMMI demonstration projects typically involve copious amounts of monitoring of outcomes and costs. Allmon is skeptical about measuring outcomes of GLP-1 coverage, noting that a CMMI oncology care program failed to show savings despite comprehensive tracking.

“When you look at obesity drugs, understanding what the outcomes have been, how that has changed and where the costs have decreased while you're paying for these drugs is going to be imperative. But I don’t know how they are going to do that,” she says.

Measuring outcomes for obesity drugs presents unique challenges, in Allmon’s opinion. Although reductions in diabetes diagnoses or cardiovascular events might be trackable, Allmon questions whether meaningful health improvements can occur if patients don't start treatment until they are eligible for Medicare at age 65. “If you're obese enough at 65 to qualify, has there already been a lot of damage done to your heart?” she asks.

The CMMI program appears to be voluntary for manufacturers, who must apply to participate. “I don’t know that we are going to understand the details of what happens on the back end between the plans and the manufacturers so that the plans can afford to cover them for $50 a month,” Allmon says.

Direct to patient

The White House lumped the CMMI $50 copay program in with the direct-to-consumer sales of the obesity drugs and the TrumpRx website in its November announcement, but it is really quite separate. TrumpRx, which President Donald Trump announced on Sept. 30, 2025, doesn’t sell medicines but acts as a clearinghouse, directing cash-pay patients to other platforms. To date, 10 pharmaceutical companies are offering 27 different products for sale directly to consumers through various online platforms.

Direct-to-consumer drug sales outside of insurance coverage predate TrumpRx. The Mark Cuban Cost Plus Drug Company sells generics at cost with set markups. Eli Lilly and Company then launched LillyDirect, a direct-to-consumer program launched in January 2024, mainly to sell its diabetes and weight loss drug, tirzepatide, sold under the brand names Mounjaro for diabetes and Zepbound, at approximately half the list price of around $1,000 a month.

With demand for the weight loss drugs sky high and insurance coverage spotty, and Medicare explicitly prohibited from covering weight loss, Lilly saw an opportunity for direct-to-consumer sales. In a recent earnings call, company officials said that a fifth of Zepbound sales are from cash-pay patients.

Trump’s most-favored-nation drug pricing policies have included a push on drugmakers to create direct-to-consumer channels with drugs priced at levels similar to or lower than those offered overseas. As part of the Nov. 6 announcement, Lilly and Novo Nordisk agreed to lower the prices of some of their investigational GLP-1 drugs to treat diabetes and obesity once the FDA has approved them.

Lilly also agreed to discount its Zepbound multidose pen once approved by the FDA. The drug is currently approved as a once-weekly injection in a prefilled single-dose pen or vial. Lilly said the Zepbound multidose pen will be available at the lowest dose, 2.5 milligrams, at $299 per month, with higher doses costing up to $449. Those prices are $50 cheaper than the monthly direct-to-consumer prices of the single-dose vials sold on LillyDirect. The company said in a press release that the lower prices are similar to what is available in Europe.

Orforglipron is Lilly’s oral GLP-1 in phase 3 development as a treatment for diabetes and obesity. The FDA is expected to approve the drug in March 2026. Lilly’s November news release states that the drug will be priced at $149 per month at the lowest dose, with additional doses priced at up to $399 per month.

The White House stated when it announced the discounts that Novo Nordisk’s Wegovy and Ozempic, both of which are semaglutide products, will be sold at $350 per month when bought through TrumpRx. Additionally, an oral formulation of Wegovy, currently under review by the FDA, would have an initial dose price of $149 across all direct-to-consumer offerings. And just this week, Novo Nordisk announced it would discount the first two doses of Wegovy and Ozempic to $199 for self-pay patients.

Allmon said direct-to-consumer sales are a positive for some people, but she raised concerns about patient safety in direct-to-consumer models. Traditional pharmacy benefit managers (PBMs), despite widespread criticism, provide valuable clinical safeguards, including monitoring for drug-drug interactions, duplicate therapies and contraindications.

“It puts more responsibility on the doctor to make sure they’re not writing something the patient is allergic to or already has a prescription for from somebody else.” She questioned who would remind physicians of clinical standards or alert them to potential problems when prescriptions bypass traditional pharmacy systems.