Weight-Loss Drug Wegovy will be Covered by US Medicare for Heart Disease Patients

The agency overseeing the U.S. Medicare program said on Thursday, March 21, 2024, that the program will now cover Wegovy, the weight loss medication developed by Novo Nordisk. The caveat is that insured patients will be covered if the drug was prescribed to lower their risk of heart attack and stroke. In other words, the US Medicare program will not cover the prescription of Wegovy if it has nothing to do with lowering the risk of heart disease. 

Currently, Part D or Medicare prescription drug plans administered by private insurers don’t cover obesity drugs. However, with the new guidance, such drugs will be paid for if they receive U.S. approval for secondary use that the Medicare program covers, according to the U.S. Centers for Medicare and Medicaid Services (CMS). 

In a statement sent through email, the CMS spokesperson said, “CMS has issued guidance to Medicare Part D plans stating that anti-obesity medications that receive FDA approval for an additional medically accepted indication can be considered a Part D drug for that specific use”.

Earlier this month, the FDA approved Wegovy following large-scale positive results from clinical trials. The drug lowered the risk of heart attack and stroke in obese and overweight non-diabetic adults.

The new guideline will also mandate State Medicaid programs for low-income people and families to cover Wegovy when used to prevent heart disease among obese people, according to the CMS spokesperson.

The future of Wegovy and other weight loss medications is promising

Analysts forecast that the weight loss drug market could reach a $100 billion annual valuation by the end of the decade. The demand has risen astronomically and products like Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound and Mounjaro are struggling to keep up with demand. 

With the coverage of Wegovy by Medicare, the drug is now open to government price negotiations under the Inflation Reduction Act signed into law by President Joe Biden. According to CMS, any price negotiation will apply to all drugs that share the same active ingredient rather than to individual brands.

Last year, Novo Nordisk told analysts that it expected Medicare to negotiate the price it would pay for Ozempic which has semaglutide as its active ingredient. The company expects the new price to be published in 2027 and said it anticipated that Wegovy would be affected by the negotiations because it shared the same active ingredient with Ozempic.

Medicare still has a long list of drugs it doesn’t cover

Under the Social Security Act, Medicare is still barred from covering drugs used for the treatment of weight gain, weight loss, and anorexia. Under the new guidance shared by CMS, weight loss drugs are still not covered by Medicare when their sole use is to treat obesity.

“A drug that receives FDA approval for chronic weight management alone would not be considered a Part D drug,” the CMS spokesperson said. “If this same drug also receives FDA approval to treat diabetes or reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight, then it would be considered a Part D drug for those specific uses only.”

Medicare is an insurance program by the U.S. government designed for people aged 65 years and older and those living with one form of disability. It is believed that around 65 million people are currently enrolled in the program.