A recent study reveals that millions of overweight or obese Medicare patients with heart conditions could potentially gain access to the well-known weight-loss medication Wegovy. Wegovy, scientifically known as semaglutide, received approval from the U.S. Food and Drug Administration (FDA) last month for lowering the risk of heart attack and stroke in overweight or obese adults without diabetes.
The study, published by the Kaiser Family Foundation (KFF), estimates that 7% of Medicare beneficiaries, or 3.6 million individuals, had established cardiovascular disease and were overweight or obese in 2020, potentially making them eligible for coverage of Wegovy for its new indication. Among these patients, 1.9 million also had diabetes, according to the KFF study, and may have already qualified for Medicare coverage of Wegovy and Novo’s widely used diabetes drug, Ozempic.
Since Medicare is restricted by law from covering Wegovy and other weight-loss medications solely for weight loss, coverage for Wegovy under its new indication would be provided through drug plans administered by private insurers, known as Part D. The KFF study indicates that broader coverage may become more likely in 2025, although some Part D plans have announced they will begin covering Wegovy in 2024.
The study emphasizes that the impact of expanded Wegovy coverage on Medicare spending is contingent on several factors, including the number of Part D plans that include coverage, the extent of restrictions imposed by these plans, the number of eligible individuals who utilize the medication, and the negotiated prices paid by the plans.
The U.S. Centers for Medicare and Medicaid Services (CMS) issued a memo last month clarifying that Part D plans can cover Wegovy now that it has an indication beyond Medicare’s excluded coverage. A spokesperson for the federal agency stated, “CMS has issued guidance to Medicare Part D plans stating that anti-obesity medications (AOMs) that receive FDA approval for an additional medically accepted indication can be considered a Part D drug for that specific use.”
The study acknowledges that not all Medicare patients eligible for Wegovy are likely to use it due to potential out-of-pocket costs, ranging from $325 to $430 per month before reaching the annual cap of $2,000, as well as potential side effects of the drug. The FDA prescribing information for Wegovy includes a warning to healthcare professionals about the risk of thyroid C-cell tumors and advises against its use in patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.
A spokesperson for Novo Nordisk emphasized that the company “is continuously performing surveillance of the data from ongoing clinical trials and real-world use of its products and collaborates closely with the authorities to ensure patient safety and adequate information to healthcare professionals.” It is important to note that this news article is not intended to provide medical advice and should not be relied upon as a substitute for professional consultation with a qualified healthcare provider familiar with your individual medical needs.
