Potential Changes to Medicare Coverage

Medicare patients may soon be eligible for coverage of the obesity drug Wegovy, as Novo Nordisk has revised its prescription marketing to highlight the drug’s ability to reduce cardiovascular risks in addition to its anti-obesity benefits.

In the past, Medicare did not cover this medication because it was prescribed for the treatment of obesity, which goes against the current Medicare coverage rules.

The drug’s new label now states that it can be utilized to minimize the chances of heart disease.

According to Vivian Yu, a dietician, nutritionist, and co-founder of Gym Near Me, Medicare has not covered weight loss medication due to a lack of strong evidence regarding their effectiveness and concerns about potential side effects. However, Yu notes that the recent FDA approval of Wegovy for heart disease is a significant development that is changing the landscape.

According to the Centers for Medicare and Medicaid Services, approximately 40 percent of Medicare recipients have at least one heart condition. This suggests that a considerable number of them may be eligible for the weight loss drug, Wegovy. However, it’s important to note that Medicare only covers weight loss drugs like Wegovy if they are prescribed for diabetes.

Drugmakers are actively lobbying Congress and pushing the FDA to approve the drugs for conditions such as kidney disease and sleep apnea, which are strongly associated with obesity. Although there hasn’t been an official change in the ban yet, the pharmaceutical companies are making efforts to bring about a revision.

The FDA has granted approval to Wegovy for the treatment of cardiovascular conditions. However, the coverage of Wegovy under this revised prescription classification will be determined by the Centers for Medicare and Medicaid Services.

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It is expected that plans will not be altered to include Wegovy until the following year. However, if permitted, Part D plans may promote medication coverage as a selling point to those who qualify for Medicare.

According to Louise Norris, a health policy analyst for MedicareResources.org, if a patient has a condition that can be treated by a weight loss drug that has FDA approval for another condition, their doctor can prescribe it for that condition. In such cases, there is a possibility that the drug may be covered by their Part D plan.

The implications of this will vary for each individual, as it depends on the specific medical conditions they have and the approach their doctor believes is most suitable for managing those conditions.

According to Yu, there are still individuals who oppose Medicare’s coverage of Wegovy, primarily due to its high price. The drug remains quite expensive, with a list price exceeding $1,300 for a 28-day supply. As a result, Medicare could face a substantial financial burden, considering that a significant portion of the population may be eligible for this medication.

There are concerns among some individuals that these drugs may be excessively utilized as a quick solution for weight loss, without considering the long-term sustainability.

According to Yu, many individuals have been misled by social media into thinking that weight loss drugs are a quick fix, without being fully aware of the potential side effects associated with them.

Wegovy has been associated with potential side effects including diarrhea, stomach pain, vomiting, headache, and tiredness. Certain patients have reported experiencing low blood sugar levels and thyroid tumors. It is important to note that regardless of the weight loss medication selected, there are inherent risks of encountering side effects.

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According to Yu, it is important to note that, similar to Wegovy, any weight loss medication must receive FDA approval for treating a weight-related health condition rather than solely focusing on weight loss. Additionally, Medicare does not approve medications that provide short-term benefits or have low efficacy, as the potential risks should not outweigh the benefits.

In the end, Yu expressed concern that the price of Wegovy could still hinder its inclusion in Medicare’s coverage.

According to Yu, Medicare prescription drug plans may be reluctant to cover Wegovy due to its high cost and the potential strain it could put on program budgets. This hesitation could be attributed to the availability of other cheaper generic drugs in the market that also aim to reduce the risk of heart disease.

Other obesity medications may also have a similar effect on heart attack risk, which could potentially lead to them seeking FDA approval and Medicare coverage in the future.

Medicare beneficiaries should not be too quick to celebrate, as Norris advises that the out-of-pocket costs of plans can differ greatly.

According to Norris, it is crucial for Part D and Medicare Advantage enrollees to engage in comparison shopping every year during the fall enrollment period. This will enable them to determine whether their current medications could be better covered under an alternative plan.

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