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Medicare to Cover Wegovy When Patients Also Have Heart Disease

Medically reviewed by Judith Stewart, BPharm. Last updated on March 22, 2024.

By Robin Foster HealthDay Reporter

FRIDAY, March 22, 2024 -- Medicare will now cover the popular weight-loss drug Wegovy if patients using it also have heart disease, U.S. officials announced Thursday.

The move comes after the U.S. Food and Drug Administration approved drugmaker Novo Nordisk’s application to add cardiovascular benefits to the medicine’s label earlier this month.

As a result, the U.S. Centers for Medicare and Medicaid Services (CMS) said it has informed insurers that provide Medicare Part D drug plans that they could cover the medication if it is approved for another use.

“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,” CMS said in a statement, CNN reported.

Part D plans could begin covering the drug “some time this year,” Tricia Neuman, a Medicare policy specialist at KFF, told the Associated Press.

“Medicare plans may be reluctant to move quickly to cover Wegovy given its relatively high price, particularly because they won’t be able to adjust premiums before next year,” she said. Wegovy costs just over $1,300 a month.

Even if plans do allow coverage, they may still require higher out-of-pocket fees, prior authorizations or step therapy, where a patient must try a lower-cost drug before proceeding to the new treatment, Neuman noted.

Wegovy is one of four popular weight-loss medications called GLP-1 receptor agonists. Two of them, Novo Nordisk’s Ozempic and Eli Lilly’s Mounjaro, are approved to treat people with diabetes and are more likely to be covered by insurers, CNN reported.

But Wegovy and Eli Lilly’s Zepbound were only approved as weight-loss drugs, until the FDA’s recent expanded approval for Wegovy's heart benefits. That means they have been much less likely to be covered by insurance.

Medicare is not allowed by law to cover weight-loss drugs, although Congress is facing pressure to change that, CNN reported. But if the medication also receives FDA approval to lower the chances of heart attacks, strokes and other cardiovascular events, it can be added to Part D programs for people with heart disease, the CMS said.

The CMS also said that states would be required to cover Wegovy in their Medicaid plans to prevent heart disease in people with obesity, but they could also take steps to control usage, such as requiring patients to try other medications or treatments first, CNN reported.

Though the drugmakers provide some discounts for all four medications, their high list prices put them out of reach for many Americans, CNN reported.

One lingering obstacle to broader use is limited supply of the drug, which has been in shortage for more than a year, according to the FDA. Novo Nordisk officials say they’re working to increase production and access, the AP reported.

Disclaimer: Statistical data in medical articles provide general trends and do not pertain to individuals. Individual factors can vary greatly. Always seek personalized medical advice for individual healthcare decisions.

© 2024 HealthDay. All rights reserved.

Posted March 2024

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