More than 3 million Medicare patients could be eligible for coverage of Wegovy to reduce heart disease risks, study says

More
than
3
million
people
with

Medicare
could
be
eligible
for
coverage
of

Wegovy
now
that
the
blockbuster
weight
loss
drug
is
also

approved
in
the
U.S.
for
heart
health,
according
to
an
analysis
released
Wednesday
by
health
policy
research
organization
KFF.

But
some
eligible
beneficiaries
could
still
face
out-of-pocket
costs
for
the
highly
popular
and
expensive
drug,
KFF
said.
Certain
Medicare
prescription
drug
plans
may
also
wait
until
2025
to
cover
Wegovy.

Medicare’s
budget
could
be
strained
as
more
plans
cover
the
costs
of
Wegovy.
The
program’s
prescription
drug
plans
could
spend
an
additional
net
$2.8
billion
if
just
10%
of
the
eligible
population,
an
estimated
360,000
people,
use
the
drug
for
a
full
year,
according
to
KFF.

Under

new
guidance
issued
in
March,
Medicare
Part
D
plans
can
cover
Wegovy
for
patients
as
long
as
they
are
obese
or
overweight,
have
a
history
of
heart
disease
and
are
specifically
prescribed
the
weekly
injection
to
reduce
their
risk
of
heart
attacks
and
strokes.
The
Food
and
Drug
Administration
approved
Wegovy
for
that
purpose
in
March.

KFF
said
that
applies
to
3.6
million,
or
7%,
of
total
beneficiaries,
based
on
2020
data.
That
group
also
makes
up
1
in
4
of
the
13.7
million
Medicare
patients
who
are
obese
or
overweight. Those
numbers
may
be
higher
based
on
more
recent
data,
the
nonprofit
group
said.

The
analysis
suggests
that,
for
the
first
time,
certain
Medicare
beneficiaries
will
be
able
to
access


Novo
Nordisk‘s
Wegovy
without
having
to
shoulder
the
total
$1,300
monthly
price
tag
alone.

Notably,
Medicare
prescription
drug
plans
administered
by
private
insurers,
known
as
Part
D,
currently
cannot
cover
Wegovy
and
other
GLP-1
drugs
for
weight
loss
alone.
GLP-1s
are
a
buzzy
class
of
obesity
and
diabetes
treatments
that
work
by
mimicking
a
hormone
produced
in
the
gut
to
suppress
a
person’s
appetite
and
regulate
their
blood
sugar. 

But
KFF’s
analysis
found
that
Medicare
beneficiaries
who
take
Wegovy
could
still
face
monthly
out-of-pocket
costs
of
$325
to
$430
if
they
have
to
pay
a
percentage
of
the
drug’s
list
price
for
a
month’s
supply.

A
new
Part
D
cap
on
out-of-pocket
spending
would
limit
beneficiaries’
out-of-pocket
costs
to
around
$3,300
in
2024
and
$2,000
in
2025.
Still,
those
sums
are
a
significant
burden
for
those
who
live
on
modest
incomes.

Some
patients
also
may
struggle
to
access
Wegovy
if
Part
D
plans
that
decide
to
cover
it
implement
certain
requirements
to
control
costs
and
ensure
the
drug
is
being
used
appropriately.
That
could
include “step
therapy,”
which
requires
plan
members
to
try
other
lower-cost
medications
or
means
of
losing
weight
before
using
a
GLP-1
such
as
Wegovy.

“These
factors
could
have
a
dampening
effect
on
use
by
Medicare
beneficiaries,
even
among
the
target
population,”
KFF
wrote
in
its
analysis.

Some
Part
D
plans
have
already

announced
that
they
will
begin
covering
Wegovy
this
year,
but
it’s
unclear
how
widespread
coverage
will
be.
KFF
said
many
plans
may
be
reluctant
to
expand
coverage
now
since
they
can’t
adjust
their
premiums
mid-year
to
account
for
higher
costs
associated
with
use
of
the
drug.

That
means
broader
coverage
in
2025
could
be
more
likely,
KFF
added.

Medicare
already
covers
GLP-1s
and
other
treatments
for
diabetes,
such
as
Novo
Nordisk’s
blockbuster
Ozempic. 

Among
the
Medicare
beneficiaries
who
are
obese
or
overweight
and
have
a
history
of
heart
disease,
1.9
million
also
have
diabetes,
according
to
KFF.
That
makes
them
already
eligible
for
Medicare
coverage
of
other
GLP-1
drugs
approved
for
that
condition.