United States – Medicare can pay for the vastly popular weight-loss drug Wegovy only in the case when patients take it together with other medications used for decreasing the risk for future heart attacks, strokes, as well as other severe conditions, the federal officials clarified on Thursday.
New Coverage Guidance
This is actually important, as the Centers for Medicare & Medicaid Services issued new guidance saying that Medicare Part D drug benefit plans—which are given through private insurers—could cover anti-obesity drugs if they were approved under that condition, too, as reported by The Associated Press.
The decision would be the starting signal for a multitude of new prescriptions, which comes along with a total expenditure of a lot of dollars, the experts have noted.
In practice, the guidance clears the way for coverage of Wegovy, the brand name of semaglutide, by health plans and insurers. The FDA just this month approved an option that allows Wegovy to be applied to lower cardiovascular event risk in people who are overweight or obese and already have heart disease.
The most recent data informed that Wegovy reduced heart attack, stroke, and other issues by 20% in these patients compared to the placebo or inactive drug. Cardiologists and other experts noted that the use of semaglutide to reduce the risk of unpreventable and dangerous situations could shift the paradigm in the way heart patients are treated.
Financial Considerations
Wegovy costs more than $ 1,300 a month, or $ 16,000 per year.
Tricia Neuman, a KFF specialist on Medicare health policy, said the drugs may be included in the Part D plans “by the end of this year.”
“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.
Even if plans still allow coverage, people who fit this criterion may have other restrictions. Budgetary plans may contain higher copayments, prior approvals, or step therapy, in which a patient is requested to take a less pricey drug first before moving to the new treatment, as Neuman said.
Medications for chronic weight management are specific only as these are prohibited by Part D plans, CMS officials confirmed.
Awaiting Coverage Decisions
Private insurers are still reviewing the guidance from the FDA while they are awaiting the new drug indication for Wegovy. When that is done, coverage decisions will be made, said a spokesperson for AHIP, America’s Health Insurance Plans, an industry grid group.
Drugmakers and obesity educators together have pushed to get expanded insurance changes, including a bill that will make it necessary for Medicare to cover obesity medications.
The key issue is whether the high costs of the medications will be recovered through reducing expenditure on healthcare because of reduced medical bills associated with obesity — and now, heart ailments, as reported by The Associated Press.
Limited Availability
The only challenge in the widespread adoption of this drug is that there is a limited amount of the drug, and it has been in shortage for more than a year, the FDA records. According to Novo Nordisk managers, efforts are underway to increase the productivity and accessibility of the drug.