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Medicare Part D to cover cost of Wegovy when used to reduce risks of heart conditions

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Article

CMS issues guidance and won’t pay for the drug for weight loss exclusively.

wegovy injection semaglutide obesity © Tobias Arhelger - stock.adobe.com

© Tobias Arhelger - stock.adobe.com

Medicare Part D will pay for the antiobesity drug Wegovy (semaglutide) when prescribed to cut risks of heart disease.

The U.S. Centers for Medicare & Medicaid Services this week issued guidance that current Medicare Part D and Medicaid coverage rules apply to the drug making headlines for its health effects including weight loss.

Reports about the change in Medicare policy surfaced this week starting in the Wall Street Journal.

The Medicare Part D coverage process

Glucagon-like peptide-1 receptor agonist drugs (GLP-1 RAs) have gained attention of physicians and the public.

Since its beginning in 2006, Medicare Part D has excluded from basic coverage all drugs when used exclusively for weight loss. That includes “agents used for anorexia, weight loss, and weight gain,” according to a CMS statement sent to Medical Economics.

Medicare Part D has not changed that policy and will not cover antiobesity medications when used for chronic weight management in patients who do not have an additional medically accepted condition, unless provided as a supplemental benefit by the Part D plan, said the statement from a CMS spokesperson.

But if the medication is approved by the U.S. Food and Drug Administration (FDA) for an additional medically accepted indication, such as diabetes or reducing risk of major adverse cardiovascular events in patients with overweight or obesity, Medicare Part D can consider it, according to CMS.

That happened for Wegovy: On March 8, the FDA approved the injection to reduce risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and obesity or overweight.

Coverage issues

Regarding coverage for Wegovy, the CMS statement noted Medicare Part D plans may use management tools such as prior authorization, step therapy and quantity limits

For Medicaid, states would be required to cover Wegovy for the purposes to prevent cardiovascular disease in people with obesity. States will also be able to use utilization management and step therapy in covering Wegovy for this purpose.

In Medicaid, “states would be required to cover Wegovy for the purposes to prevent cardiovascular disease in people with obesity,” the CMS statement said. “States will also be able to use utilization management and step therapy in covering Wegovy for this purpose.”

Where’s the Wegovy?

Pharmaceutical giant Novo Nordisk announced the company would more than double the amount of the lower-dose strengths of Wegovy in the U.S. market starting in January. Manufacturing lines are operating 24 hours a day, seven days a week, but “it’s important to be aware that overall demand will continue to exceed supply, which means that some patients may still have difficulty filling Wegovy prescriptions,” according to the company.

Since the FDA approval in 2021, more than 1 million American patients have taken the drug, and more than 600,000 are using it now to manage weight, according to Novo Nordisk.

Covering costs

Wegovy currently costs $1,349.02, although most people don’t pay that list price if insurance covers it, according to Novo Nordisk’s NovoCare website.

It was unclear if the CMS guidance might add to political efforts to change Medicare policy to pay for antiobesity medications. Two physicians in Congress, Rep. Brad Wenstrup, DPM (R-Ohio), and Rep. Raul Ruiz, MD (D-California) have introduced the “Treat and Reduce Obesity Act,” which would expand Medicare payment for antiobesity medications and other services for treating obesity. That bill has bipartisan support from some doctors in Congress and remains pending in the House of Representatives.

Last year, the American Medical Association (AMA) endorsed the concept of insurance companies covering costs to help patients access the new drugs. The GLP-1 RAs are costly, but so are the health consequences of obesity, according to AMA.

In a survey last year by the University of Michigan National Poll on Healthy Aging, 83% of older adults agreed health insurance should pay for FDA-approved prescription medications for weight management, and 76% said Medicare should be required to pay for the drugs, although just 30% said they were willing to pay more for their Medicare premiums to have the medications covered.

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