Medicare can cover the well-known weight loss medication Wegovy if the patients also have heart disease and need to lower the risk of future heart attacks, strokes, and other severe issues, according to federal officials.
A new guidance from the Centers for Medicare & Medicaid Services states that Medicare Part D drug benefit plans, provided by private insurers, could pay for anti-obesity drugs with additional approved uses.
The change could lead to a significant increase in prescriptions and billions of dollars in extra spending, according to analysts.
In essence, the guidance allows for broader coverage of Wegovy, the brand name for Novo Nordisk’s obesity medication semaglutide, as the U.S. Food and Drug Administration has approved its use to lower the risk of cardiovascular events in overweight or obese individuals with existing heart disease.
Recent studies demonstrated that Wegovy reduced the risk of heart attack, stroke, and other problems by 20% compared to a placebo in such patients. Cardiologists and other experts believe that using semaglutide to decrease the risk of often fatal or disabling conditions could revolutionize the treatment of heart patients.
Wegovy costs over $1,300 per month, which amounts to more than $16,000 annually.
According to Tricia Neuman, a Medicare policy expert at KFF, a nonprofit focusing on health policy research, Part D plans may start covering the drug sometime this year.
Neuman pointed out that Medicare plans might hesitate to quickly cover Wegovy due to its relatively high cost, especially since they will not be able to adjust premiums until next year.
Even if plans do decide to provide coverage, eligible individuals may still encounter other limitations such as higher out-of-pocket expenses, prior authorizations, or step therapy, which requires patients to try a lower-cost drug before moving on to the new treatment, Neuman stated.
CMS officials clarified that Medicare Part D plans are legally prohibited from covering obesity medications solely used for chronic weight management, and that will not change.
A spokesperson for AHIP, America’s Health Insurance Plans, an industry trade group, mentioned that private insurers are assessing the guidance and the new indication for Wegovy before making coverage decisions.
Drug manufacturers and advocates for obesity treatment have been advocating for expanded coverage, including legislation that would mandate Medicare to pay for obesity medications.
The main question has been whether the cost of these expensive medications will be compensated by the savings from reduced spending on medical care related to obesity, and now, heart disease.
A lingering challenge to wider usage is the limited supply of the drug, which has been in shortage for over a year, as per the FDA. Novo Nordisk officials state that they are working to enhance production and access.
