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- Medicare drug plans can now cover Wegoby, an anti-obesity drug prescribed to lower the risk of heart disease and stroke.
- This comes after the FDA expanded the drug’s approval to include cardiovascular effects.
- Clinical trials have shown that Wegovy reduces the risk of cardiovascular events such as heart attack and stroke in people living with obesity or overweight.
Medicare plans can begin covering anti-obesity drugs like Wegovy to enrollees as long as they are prescribed to reduce the risk of heart attacks and strokes, the agency overseeing the program said on March 21. Announced.
The move came after the Food and Drug Administration.
“CMS [The Centers for Medicare and Medicaid Services] Provides that for Medicare Part D plans, anti-obesity medications (AOMs) that are FDA-approved for additional medically recognized indications may be considered Part D drugs for that specific use. guidance,” the agency said in a statement.
Congress passed a rule in 2003 that would prohibit Medicare from covering chronic weight management drugs if they are used solely for weight loss. However, if the same drug receives FDA approval for medically recognized uses such as cardiovascular disease or type 2 diabetes, it may be eligible for Medicare prescription drug plans.
CMS said in a statement that to ensure that Wegovy is used to reduce the risk of cardiovascular disease, Part D plans may require enrollees to receive prior approval (also known as pre-approval) from the plan.
The agency also said state Medicaid plans will be required to cover Wegovy to reduce the risk of cardiovascular disease in people living with obesity or overweight.
However, your plan may require you to try other drugs or treatments first.
of wall street journal We were the first to report the CMS guidance.
Wegovy is a type of drug called a GLP-1 receptor agonist and is one of four drugs in this class on the market.
Wegovy and Eli Lilly’s Zepbound was initially approved by the FDA solely for chronic weight management. Wegovy’s approval was subsequently expanded to include cardiovascular effects.
Two other drugs in the same class, Novo’s Ozempic and Lilly’s Munjaro, are approved to treat patients with type 2 diabetes. Therefore, Medicare Part D plans and commercial insurance plans are more likely to cover these drugs.
Wegovy and Ozempic share the same active ingredient semaglutide. Similarly, Mounjaro and Zepbound both contain tirzepatide and are dual-acting drugs that target both the GLP-1 and GIP hormones.
FDA expansion
Endocrinologist and Ro advisor Dr. Beverly Chan said Wegovy’s Medicare coverage for people with cardiovascular disease is a big step in the right direction.
“Why should we wait for obese people to develop diabetes or heart disease when we can treat them early and prevent further complications?” she told Healthline. “I know many patients who would benefit from this, and I hope private insurance companies will follow suit.”
Dr. Angela Fitch, Knowwell’s chief medical officer and current president of the Obesity Medicine Society, agrees: “This is one of the most important populations to treat.” “If we can reduce someone’s risk of having another stroke or heart attack by 20 percent, that’s a pretty big deal.”
But she believes Wegovy and other anti-obesity drugs should be covered by Medicare and private insurance companies even without FDA approval for their cardiovascular effects.
“We have drugs that can improve patients’ quality of life, extend their lives and reduce their risk of other diseases,” Fitch told Healthline. “So [doctors] We should be able to get this medicine to people who need it. ”
Some lawmakers are pushing to make anti-obesity drugs more accessible to Medicare enrollees. The bipartisan Treatment and Reduction of Obesity Act (TROA) would allow Medicare to cover FDA-approved chronic weight management drugs, even if they are prescribed solely for weight loss.
Fitch hopes that expanding coverage of medicines like Wegoby will also reduce the stigma associated with obesity, which prevents some people from receiving regular medical care.
“At Knownwell, we have patients who come to us who haven’t seen a doctor in 10 years and who have several chronic conditions that we can’t treat,” she said. [about their weight]Even if it’s an unintentional bias by the medical team. ”
Both Novo and Lilly offer several discounts on these four medications. But the high list prices of these drugs put them out of reach for many Americans unless their insurance companies cover them at lower prices.
The Congressional Budget Office expects semaglutide to be selected for government price negotiations within the next few years under the Biden administration’s Inflation Control Act. Although this only applies directly to Medicare, the move could also impact the decisions of private insurers.
CMS previously said the negotiated prices would apply to drugs containing the same active ingredient, not individual brand-name drugs such as Wegovy or Ozempic.
There has been a huge demand for these drugs since they were approved by the FDA. Wegovy’s expanded coverage could make the situation even worse unless drug companies increase manufacturing supply.
However, Fitch said it will take longer for insurers to cover the drugs for a limited number of patients.
Some patients have had to skip doses because their pharmacies don’t have it or they can’t afford it, she said. If a patient misses a dose, they may have to start the drug again at a lower initial dose.
So, “from a coverage perspective, it’s not just about expanding access. It’s about delivering care efficiently and safely,” she said. “Because these are very expensive drugs and no doses should be wasted.”
Medicare Part D prescription drug plans can now also cover anti-obesity drugs that are FDA-approved for other medically recognized indications, such as treating type 2 diabetes or reducing cardiovascular disease. Ta.
As a result of this change, Part D plans can now also cover Novo Nordisk’s Wegovy, which received expanded approval from the FDA for its cardiovascular effects earlier this year.
In clinical trials, Wegovy was shown to reduce the risk of major cardiovascular events, such as heart attack and stroke, in people living with obesity or overweight and who did not have type 2 diabetes.
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