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Medicare Part D pays for the anti-obesity drug Wegovy (semaglutide), which is prescribed to reduce the risk of heart disease.

The U.S. Centers for Medicare and Medicaid Services this week issued guidance that current Medicare Part D and Medicaid coverage rules will apply to drugs that have been discussed for their health effects, such as weight loss.

This week, reports surfaced about changes to Medicare policy from 2019. wall street journal.

Medicare Part D Application Process

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

Since its inception in 2006, Medicare Part D has excluded from basic coverage all drugs used solely for weight loss. This includes “drugs used to treat anorexia, weight loss, and weight gain,” according to a CMS statement sent to . health economics.

According to a statement from CMS, Medicare Part D has not changed its policy and states that when anti-obesity drugs are used for chronic weight management in patients without additional medically recognized conditions, Part D plans It does not cover anti-obesity drugs unless they are offered as a supplemental benefit. Public Relations Officer.

However, if the drug is approved by the U.S. Food and Drug Administration (FDA) for additional medically recognized indications, such as reducing the risk of serious cardiovascular events in patients with diabetes or who are overweight or obese, Medicare Part D could consider that. CMS.

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

Scope issues

Regarding Wegovy coverage, the CMS statement states that Medicare Part D plans may use administrative tools such as prior authorization, step therapy, and quantity limits.

For Medicaid, states would be required to cover Wegovy to prevent cardiovascular disease in obese people. States can also use utilization management and step therapy in covering her Wegovy for this purpose.

Under Medicaid, “states will be required to cover Wegovy for the purpose of preventing cardiovascular disease among obese people,” the CMS statement said. “States may also utilize utilization management and step therapy in covering Wegovy for this purpose.”

Where is Wegobee?

Pharmaceutical giant Novo Nordisk has announced it will more than double the strength of its low-dose Wegoby in the U.S. market starting in January. Although production lines run 24/7, it is important to note that “overall demand continues to outstrip supply, which means some patients will still be unable to fill Wegovy prescriptions.” may be difficult,” the company said.

More than 1 million American patients have taken the drug since its FDA approval in 2021, and more than 600,000 people are currently using it for weight management, according to Novo Nordisk.

Burden of costs

According to Novo Nordisk’s NovoCare website, Wegovy currently costs $1,349.02, but most people won’t have to pay that list price if they have insurance.

It is unclear whether CMS’s guidance is likely to strengthen political efforts to change Medicare policy to pay for anti-obesity drugs. Two doctors in Congress, Democratic Rep. Brad Wenstrup (R-Ohio) and Dr. Raul Ruiz (D-Calif.), have proposed a “Treatment of Obesity” bill that would expand Medicare payments for things like anti-obesity drugs. and “Reduction Law” was introduced. Services for obesity treatment. The bill has bipartisan support from some doctors in Congress and is pending in the House.

Last year, the American Medical Association (AMA) endorsed the concept of insurance companies paying for new drugs to make them available to patients. According to the AMA, GLP-1 RAs are expensive, but so are the health effects of obesity.

A national poll on healthy aging conducted by the University of Michigan last year found that 83% of older adults agreed that health insurance should pay for FDA-approved prescription drugs for weight management, and 76% agreed that health insurance should pay for FDA-approved prescription drugs for weight management. answered that Medicare should pay for the drug. However, only 30% said they were willing to pay more in Medicare premiums to have their medications covered.