Access Is Coming, but Responsible Access Wins: What Trump’s GLP‑1 Price Deal May Mean for Medicare Plans

On November 6, 20205, the Trump Administration announced an agreement with Eli Lilly and Novo Nordisk to considerably reduce the cost of GLP‑1 weight‑loss and diabetes medications and expand access across Medicare and Medicaid programs. This would mark a change to the long‑standing Medicare restrictions on covering drugs “for weight loss”, with coverage projected to expand to these populations in 2026.

Expanded Access with New Projected Price Points

Key pieces of the deal include lower cash‑pay prices starting around $350/month, dropping toward approximately $245/month within two years, as reported by AP News.  For Medicare and Medicaid programs, the price point for current injectables will be around $245/month, with co‑pays for beneficiaries anticipated to be as low as $50/month. Additionally, oral GLP‑1 drugs, currently in development, are anticipated to launch at around $149/month.

The lower price point and expanded accessibility for these populations will spark a significant spike in demand, with unknown implications for drug availability as demand surges. While GLP-1s offer significant outcomes for obesity and diabetes, they also come with side effects that can impact adherence and long-term health outcomes with appropriate support. 

What This Could Mean for Direct‑to‑Consumer and Cash‑Pay Pricing

While the current focus has been on Medicare and Medicaid, the deal will likely have ripple effects across the industry. With the government setting new pricing benchmarks, manufacturers are likely to face growing pressure to lower their direct‑to‑consumer and cash prices. If the U.S. government can negotiate down to $245 per month, or $149 for future oral versions, it will be increasingly difficult to justify list prices between $500 and $1,000 per month for commercial plans. 

Total Cost of Care Will Decide the Story

Lower prices and broader access are only one step toward improved cardiometabolic health. The true measure of success for Medicare and other plans will be whether lower drug costs translate into improved health outcomes and sustainable savings. Adherence, side‑effect management, and long‑term lifestyle changes will determine whether these therapies truly move the needle or whether lack of adherence and side effects will erase potential improvements in member health, which remains the ultimate goal.

What This Means for Medicare and Medicaid 

Medicaid, Medicare Advantage, and Part D plans will need to begin preparing for the announced changes to access, including updating eligibility criteria, formulary placement, and member communication strategies. Most importantly, plans need to consider how they will maximize support for members to achieve long-term health outcomes that deliver sustained ROI.  Plans should model projections for uptake rates, therapy duration, drop‑off risk, and side‑effect costs. A readiness strategy that integrates medication management with digital coaching and behaviour‑change support will help to support medication adherence, long-term success rates, and overall ROI.

We’re entering a tipping point in cardiometabolic care. Access is expanding, and prices are dropping. But,  access alone will not equal impact. The plans that succeed will pair GLP-1s with scalable and data‑driven support systems that enable members to achieve long-term success and deliver real outcomes. At Lark, we call that responsible access, and we have built 24/7 access to AI-powered functionality to support digital coaching, access to educational materials,  resources  for understanding  side effects and tools for tracking medication adherence. If you are preparing for the changes ahead, Lark can help.