Medicare may pay for obesity drugs like Wegovy for some heart patients

Medicare may cover the price of the favored weight-loss drug Wegovy – provided that patients using it even have heart disease and wish to scale back their risk of future heart attacks, strokes and other serious problems, federal officials said Thursday.

The Centers for Medicare and Medicaid Services has issued recent guidance that claims Medicare Part D drug profit plans – offered by private insurers – can cover anti-obesity drugs approved for additional use.

Analysts say the move could pave the best way for 1000’s of recent prescriptions, which might translate into billions of dollars in additional spending.

In practice, the rules open the door to wider use of Wegova, Novo Nordisk’s brand of the obesity drug semaglutide. The U.S. Food and Drug Administration this month approved a label change that enables Wegova for use to scale back the chance of cardiovascular events in people who find themselves chubby or obese or have heart disease.

Recent studies have shown that Wegovy reduces the chance of heart attack, stroke and other problems in such patients by 20% in comparison with a placebo or dummy drug. Cardiologists and other experts say using semaglutide to scale back the chance of often fatal or disabling diseases could change the best way heart disease patients are treated.

Wegovy costs over $1,300 a month, or $16,000 a yr.

Part D plans could start covering the drug “sometime this year,” said Tricia Neuman, a Medicare policy specialist at KFF, a nonprofit health policy research organization.

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“Medicare plans may not be willing to quickly cover Wegova because of its relatively high price, particularly because they won’t be able to adjust premiums before next year,” she said.

Even if plans allow coverage, individuals who meet the factors may still face other restrictions. Plans may require higher out-of-pocket fees, prior authorizations or staged therapy, wherein a patient must try a less expensive drug before moving on to a brand new treatment, Neuman said.

The law prohibits Medicare Part D plans from covering obesity drugs used solely for chronic weight control, and that will not change, CMS officials say.

Private insurers are evaluating the rules – and the brand new indication for Wegova – before making coverage decisions, said a spokesman for AHIP, America’s Health Insurance Plans, an industry trade group.

Drugmakers and obesity advocates are calling for expanded coverage, including laws that might require Medicare to pay for obesity drugs.

At issue was whether the price of costly drugs could be offset by savings from reduced medical care costs related to obesity and, now, heart disease.

According to the FDA, one in all the remaining obstacles to wider use is the limited supply of the drug, which has been in brief supply for greater than a yr. Novo Nordisk officials say they’re working to extend production and access.