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Medicare may begin covering Wegovy for some elderly and other users with a history of heart disease after the U.S. Food and Drug Administration approved an application from drugmaker Novo Nordisk. Increase cardiovascular benefits to the drug label.
The Centers for Medicare and Medicaid Services said it notified insurers that offer Medicare Part D drug plans that they can cover the drug after the FDA expanded its approval this month.
“CMS has issued guidance to Medicare Part D plans for an additional medically acceptable indication that anti-obesity medications (AOMs) that receive FDA approval may be prescribed as a Part D drug for that specific use,” CMS said in a statement.
Medicare is not allowed by law to cover chronic weight management drugs, although Congress is facing pressure to change that. But if the same drug gets FDA approval to reduce heart attack, stroke and other major side effects, it could be added to Class D for people with heart disease, the agency said.
Insurers can use prior authorization — or prior approval — to ensure that Wegovi is used for a medically approved indication, CMS said. FDA approval applies to adults with cardiovascular disease and who are either obese or overweight.
The Wall Street Journal first reported on the CMS guidelines.
Wegovy is one of four wildly popular – and extremely expensive – drugs called GLP-1 receptor agonists. Two of them, Novo Nordisk Ozempic and Eli Lilly Mounjaro, are approved to treat people with diabetes. They are more likely to be covered by Medicare Part D plans and commercial insurers with diabetes.
But Wegovy and Eli Lilly's Zepbound were only approved as anti-obesity drugs, until the FDA's recent expansion to Wegovy. Therefore, commercial plans are much less likely to be covered by insurers and are covered by only a few state Medicaid programs.
CMS also requires states to cover Vegovin in their Medicaid plans to prevent cardiovascular disease in obese people, but may take steps to control its use, such as requiring patients to try other drugs or treatments first.
Although the drug providers offer some discounts for all four drugs High list prices Put them down Where they do not reach For many Americans. Wegovi costs $1,349 for a four-week supply, while Zippound sells for $1,060. Ozempic's list price is $969 for a four-week supply, and Mounjaro's price is $1,069.
The FDA's approval was based on a 17,000-patient study that showed people taking Wegovy had a 20% lower chance of a heart event than those taking a placebo.
“Wegovy is now the first weight-loss drug approved to help prevent life-threatening cardiovascular events in adults with cardiovascular disease and who are overweight or obese,” says the FDA Diabetes. , Dr. John Sharretts, director of the Division of Lipid Disorders and Health. Obesity, in a news release.
Although coverage of WeGoV and similar drugs could reduce other health care costs, these drugs at current prices still cost the federal government more than they save, according to a Congressional Budget Office analysis released Wednesday. Part of the cost will be covered by Medicare enrollees through higher premiums and out-of-pocket costs.
's Meg Tirell contributed to this report.