While the program won’t cover the drug for weight loss, the decision could still open access and provide a potential pathway for future efforts.
The Centers for Medicare and Medicaid Services (CMS) issued guidance for Medicare Part D plans — administered by private companies — allowing obesity drugs to be covered for beneficiaries as long as they have an approved indication for a condition other than obesity.
This comes on the heels of the Food and Drug Administration (FDA) approving the weight-loss medication Wegovy for reducing the risk of major adverse cardiovascular events like heart attack and stroke.
Wegovy is the first weight loss drug to receive FDA approval for that purpose.
“CMS is committed to ensuring that people have access to treatments and treatment options that improve health outcomes. With the recent change in the FDA approved use for Wegovy (semaglutide), current Medicare Part D and Medicaid coverage rules apply,” a CMS spokesperson said in a statement.
The agency made it clear that this consideration would only apply to anti-obesity medications indicated for “an additional medically accepted indication,” and not for drugs solely indicated for treating obesity.
However, many patients with obesity also likely have cardiovascular issues. The drug carries a list price of around $1,200 a month,
“Part D coverage is still not available for AOMs when used for chronic weight management in patients who do not have the additional medically accepted indication, unless provided as a supplemental benefit by the Part D plan,” the spokesperson added.
Remember: Medicare is legally barred from covering obesity treatments due to a 2003 bill, which was informed at the time by concerns that obesity drugs on the market — fen-phen — carried dangerous side effects.
The Treat and Reduce Obesity Act, introduced in Congress and heavily lobbied for by the pharmaceutical industry, would clear the way for Medicare to not only cover anti-obesity medications but also counseling services.
