Medicare Coverage: Wegovy and Weight Loss Drugs Potentially Covered by Insurance Provider
The landscape of Medicare coverage may be on the verge of a significant change with the potential inclusion of Wegovy and other weight loss drugs. The recent approval by the US Food and Drug Administration (FDA) to add cardiovascular benefits to Novo Nordisk’s medication, Wegovy, has opened up possibilities for Medicare beneficiaries with a history of heart disease.
The Centers for Medicare and Medicaid Services (CMS) have informed insurers that provide Medicare Part D drug plans that they can now consider covering Wegovy. This decision comes as a result of the FDA expanding its approval for the medication. In a statement, CMS explained, “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.”
It is important to note that Medicare is currently restricted by law from covering drugs for chronic weight management. However, there is growing pressure on Congress to revise this restriction. If a weight loss medication, such as Wegovy, receives FDA approval to reduce the risk of heart attacks, strokes, and other major adverse cardiovascular events, it could potentially be added to Part D formularies for individuals with established heart disease.
To ensure appropriate usage of Wegovy, insurers may implement prior authorization, or advance approval processes. This step aims to verify that the medication is being used for a medically accepted indication. The FDA approval applies to adults with cardiovascular disease who are either obese or overweight.
Wegovy belongs to a class of medications called GLP-1 receptor agonists, which also includes Novo Nordisk’s Ozempic and Eli Lilly’s Mounjaro. While Ozempic and Mounjaro are approved to treat diabetes and are more likely to be covered by Medicare Part D plans and commercial insurers, Wegovy and Eli Lilly’s Zepbound were initially only approved as anti-obesity drugs. However, with the recent expanded approval for Wegovy, its coverage by insurers in commercial plans is expected to increase.
It is worth mentioning that Wegovy and similar weight loss drugs come with a hefty price tag. The high list prices of these medications make them inaccessible to many Americans. Wegovy costs $1,349 for a four-week supply, while Zepound is priced at $1,060. Ozempic and Mounjaro are priced at $969 and $1,069, respectively, for a four-week supply.
The FDA’s approval of Wegovy was based on a study involving 17,000 patients. The results of the study demonstrated that individuals taking Wegovy had a 20% lower risk of a cardiac event compared to those taking a placebo. Dr. John Sharretts, the director of the FDA’s Division of Diabetes, Lipid Disorders, and Obesity, expressed his excitement about Wegovy becoming “the first weight loss medication to also be approved to help prevent life-threatening cardiovascular events in adults with cardiovascular disease and either obesity or overweight.”
While the inclusion of Wegovy and similar weight loss drugs in Medicare coverage could potentially reduce other healthcare spending, a Congressional Budget Office analysis suggests that the current prices of these medications would still cost the federal government more than they would save. This could result in Medicare enrollees experiencing higher premiums and out-of-pocket costs.
In conclusion, the potential coverage of Wegovy and other weight loss drugs by Medicare marks an important shift in healthcare accessibility for seniors and beneficiaries with a history of heart disease. The FDA’s expanded approval of Wegovy has provided an opportunity for these individuals to access medications that could reduce the risk of life-threatening cardiovascular events. However, the high cost of these drugs poses challenges in terms of affordability and cost-saving for the federal government. As discussions continue, it remains to be seen how Medicare coverage will evolve to address these issues and provide better access to necessary medications for those in need.
