Older Americans are facing significant challenges in accessing Wegovy, Novo Nordisk A/S’s weight-loss medication, through Medicare coverage. Despite the federal healthcare program’s decision to cover the drug for patients with obesity at risk of heart disease, physicians across the U.S. report numerous prescription denials by Medicare drug benefit administrators.
Several doctors interviewed by Reuters shared their experiences with repeated denials, often requiring appeals for each application. One doctor noted that none of the ten or more appeals she submits monthly are approved. Others reported success rates between 10% and 50% for patients with a history of heart attack or stroke.
Medicare’s legal restrictions prohibit coverage for weight-loss drugs and other lifestyle medications. Wegovy, administered as a weekly injection, comes with a hefty price tag exceeding $1,300 per month, prompting calls for Novo Nordisk to lower its price from the Biden administration and some lawmakers.
A July analysis by KFF, a health policy research non-profit, revealed that only 1% of Medicare plans offered coverage for Wegovy in relation to heart disease. Juliette Cubanski, KFF’s deputy director, explained that plan sponsors often delay coverage for newly approved drugs until the start of the following calendar year. She anticipates increased coverage for Wegovy in 2024, although variations in coverage for expensive medications are expected.
Eli Lilly And Co’s Zepbound, another obesity drug, is undergoing FDA approval for the treatment of obstructive sleep apnea. If approved, Medicare coverage is anticipated, potentially expanding options for older Americans.
The high cost and limited coverage of Wegovy highlight the challenges faced by older Americans struggling with obesity and the need for expanded access to effective weight-loss treatments. The situation also underscores the ongoing debate regarding the cost of prescription drugs and the need for greater affordability for patients.
