Medicare Can Now Cover Wegovy for Obesity and Heart Disease
By Anna Brooks
.jpeg)
For the first time, Medicare is allowed to cover Wegovy for people with obesity who are at risk for serious cardiovascular events.
New guidance from the Centers for Medicare and Medicaid Services (CMS) now allows Medicare Part D to cover certain weight loss drugs when prescribed to prevent heart attacks and strokes.
This includes Novo Nordisk’s Wegovy, a medication that’s surged in popularity due to its remarkable effects for treating obesity and excess weight in people without diabetes. Last month, the FDA expanded Wegovy’s uses, making it the first medication to reduce the risk of heart attacks, strokes, and cardiovascular death in people with heart disease and obesity.
“Medicare doesn’t cover any medications that are for weight loss or weight gain because they’re considered cosmetic,” said Dr. Shauna Levy, an obesity medicine specialist and medical director of the Tulane Bariatric Center.
Since 2003, Medicare has been banned from covering weight loss medications, even though many studies have shown people living with obesity and excess weight are at a greater risk for other health conditions including type 2 diabetes, heart disease, certain cancers, and more.
“These are powerful drugs that do much more than reduce weight,” said Dr. Donna Ryan, a renowned obesity researcher from the Pennington Biomedical Research Center in Louisiana. “They work on organs throughout the body and can modify the course of diabetes and heart disease.”
A huge issue for both health insurers and people who could benefit from weight loss drugs is cost. Without insurance, one month’s worth of Wegovy costs up to $1,400. The newest weight loss drug on the market, Zepbound (tirzepatide), is just over $1,000 and is not covered by Medicare.
The problem is, explained Ryan, that pharmaceutical companies offer big discounts to drug purchasers (often pharmacy benefit managers, or PBMs), but these cost-savings rarely make it down the chain to consumers.
“Frequently, PBMs do not pass on discounts to the employers who are purchasing health insurance and pharmacy benefits,” said Ryan. “That’s why PBMs are the most profitable companies in the U.S. over the last few years.”
Making things even more difficult, Medicare hasn’t been allowed to negotiate medication prices directly with drug companies – until recently. Thanks to the Inflation Reduction Act passed in 2022, Medicare has entered the first cycle of price negotiations for 10 drugs, including ones approved for diabetes, heart failure, and kidney disease.
Does Medicaid cover weight loss drugs?
Right now, Medicaid offers more flexibility than Medicare on coverage for weight loss medications – depending on what state you live in. As of 2023, the states that offer Wegovy and another weight loss drug Saxenda (liraglutide) without restrictions include:
-
California
-
Delaware
-
Minnesota
-
Rhode Island
-
Virginia
Five other states – Georgia, Michigan, New Hampshire, Pennsylvania, and Wisconsin – also offer coverage of Wegovy or Saxenda but with restrictions. This means prior authorization from health insurers is required before a medication can be prescribed or patients must take one or more alternative drugs (usually a lower-cost medication) before being prescribed their preferred medication.
The bottom line
Even though Medicare can only cover Wegovy when prescribed to prevent cardiovascular events, the drug inherently induces weight loss, making the policy change a big step forward for people living with obesity and heart disease.
“It’s a very exciting time. Anything that improves access is a victory for us,” said Levy. “This is also hopefully setting a precedent for private insurers to follow suit.”
Despite obesity being classified as a disease – not a failing of lifestyle choices, as stigma around the condition perpetuates – coverage of obesity-related medications is sorely lacking. In 2013, the Treat and Reduce Obesity Act was introduced. If passed, this legislation would provide those on Medicare access to safe and effective treatments scientifically proven to improve health outcomes for people living with obesity.
While the bill is yet to pass, this new CMS policy change is a step in the right direction in securing accessible treatments for obesity.
“These obesity medications are game changers,” said Ryan. “They have great potential to transform medical care. We need to respect these powerful medicines…they do much more than affect appetite.”
Learn more about treatments for obesity and diabetes here:
