Medicare Coverage May Be Changing

Medicare patients could soon have coverage for obesity drug Wegovy after Novo Nordisk updated the drug's prescription marketing to say it reduces cardiovascular risks instead of solely working as an anti-obesity medication.

Previously, the medication was left out of Medicare coverage since it was prescribed as obesity treatment, which is prohibited by current Medicare coverage rules.

The new label, however, says the drug can be used to reduce the risks of heart disease.

"Till now, Medicare does not cover weight loss medication because there wasn't any strong evidence of their efficacy and there were concerns about the potential side effects of these drugs," Vivian Yu, a dietician, nutritionist and co-founder of Gym Near Me, told Newsweek. "With this recent development and the FDA's approval for the usage of Wegovy for heart disease, the landscape is changing."

Roughly 40 percent of Medicare recipients have at least one heart condition, according to the Centers for Medicare and Medicaid Services, which means a significant amount could potentially be eligible for the weight loss drug. Medicare can cover weight loss drugs like Wegovy but only if patients are prescribed the medications for diabetes.

While no official change in the ban has taken place, drugmakers are lobbying Congress while pushing the FDA to approve the drugs for conditions like kidney disease and sleep apnea, which are highly correlated with obesity.

Now, the FDA has approved Wegovy for cardiovascular conditions, but it's up to the Centers for Medicare and Medicaid Services to determine how it will cover Wegovy under this updated prescription classification.

In all likelihood, plans wouldn't change to cover Wegovy until next year, but if allowed, Part D plans could use the medication coverage as a selling point when marketing to those eligible for Medicare.

"If a drug that aids in weight loss has FDA approval to treat another condition that the patient has, their doctor can prescribe it for that condition and it can potentially be covered by their Part D plan," Louise Norris, health policy analyst for MedicareResources.org, told Newsweek.

"The implications of this will vary from one person to another, since it depends on the specific medical conditions the person has, and the approach that their doctor feels will be best for managing those conditions."

Yu said there are still some opponents of Medicare's coverage of Wegovy, mostly for its price. Since the drug is still very expensive, with a list price of more than $1,300 for a 28-day supply, Medicare could find itself on the hook for a hefty bill since a large percentage of the population could qualify for it.

Others worry that the drugs would be overused as a fast track to weight loss that is not sustainable.

"Social media has led a lot of people to believe that weight loss drugs are magical bullets and they are not aware of the side effects," Yu said.

Wegovy has been linked to side effects like diarrhea, stomach pain, vomiting, headache and tiredness. Some patients have also reported low blood sugar and thyroid tumors. And no matter which weight loss drug you choose, the risks of side effects remain.

"Just like Wegovy, all weight loss medication will need FDA approval for treating a weight-related health condition, not just weight loss itself," Yu said. "Medicare also doesn't approve medications with short-term benefits, low efficacy and risks shouldn't outweigh the benefits."

Yu said that ultimately the cost of Wegovy might still put the brakes on Medicare's coverage.

"It is an expensive drug, and the coverage can strain program budgets, so Medicare prescription drug plans might be hesitant to cover Wegovy because there are other generic cheaper drugs in the market to reduce heart disease risks," Yu said.

Still, if other obesity medications have a similar effect on heart attack risk, they could pursue the same FDA approval and Medicare coverage down the line.

Norris cautions Medicare beneficiaries from celebrating as plans' out-of-pocket costs can vary significantly.

"This makes it important for Part D and Medicare Advantage enrollees to comparison shop each year during the fall enrollment period, to see if their current medications might be better covered under a different plan," Norris said.