The FDA recently approved Wegovy, a weight-loss drug, to treat overweight people with heart conditions. Will that mean that more people with Medicare will get their weight-loss drugs covered? Maya Goldman reports for Axios on what the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, as well as the insurers offering Medicare Part D prescription drug coverage, are considering.
At the moment, CMS has not decided whether Medicare will cover Wegovy as a treatment for overweight people with heart conditions. To date, Medicare has not covered any weight-loss drugs simply for the purpose of helping people lose weight. But, Medicare does cover weight-loss drugs as a treatment for people with diabetes.
Medicare, by law, covers only treatments for medically reasonable and necessary services. CMS does not consider treatment for weight loss as reasonable and necessary. Treatment for a heart condition, much like treatment for diabetes, is very different.
About 40 percent of people with Medicare have heart conditions. That’s more than 24 million people. And, likely a sizeable number of them are overweight. So, Medicare might end up covering Wegovy for them.
Of note: Wegovy costs about $1,200 a month. Covering it for even four million more people will likely cause Medicare spending to balloon. Fortunately, people with Medicare should not see their costs balloon. Beginning in 2025, people’s annual out-of-pocket costs for covered prescription drugs will be capped at $2,000.
For now, insurers offering Medicare Part D prescription drug coverage are waiting for CMS to rule on the conditions under which Medicare will cover Wegovy. Part D insurers could, of course, decide to cover Wegovy without waiting for CMS, but that would cost them a bundle. Their Medicare payments for this year are already set.
Here’s more from Just Care:
Leave a Reply