Medicare will pay for the injectable drug Wegovy for patients at higher risk of heart attacks, strokes or other serious heart-related problems, an agency spokesperson said Thursday.
The decision, according to experts, could give millions of patients access to this popular but expensive weight loss drug.
Medicare, which currently provides health insurance to more than 65 million people in the United States, has long not covered weight-loss medications.
Earlier this month, however, the Food and Drug Administration approved coverage of Wegovy, saying it can be prescribed to people who are overweight or obese to reduce the risk of heart disease.
The change prompted the Centers for Medicare and Medicaid Services to consider covering it because heart disease risk reduction is a medically acceptable use under federal law, according to the spokesperson.
Medicare will still not cover Wegovy if it is only used for weight management, the spokesperson stated.
Medicaid, the federal health insurance program for low-income people, will also be required to cover Wegovy to reduce the risk of heart disease.
Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, said Medicare offering coverage for Wegovy is “transformative.”
But doing so could potentially undermine the “financial stability” of Medicare, Gostin said. The drug costs about $1,200 a month, and many patients will likely need a prescription.
According to a poll conducted in December by the University of Michigan’s National Survey on Healthy Aging, three in four seniors believe Medicare should cover weight-loss medications.
An online publication from the Congressional Budget Office last October claimed that if Medicare covered weight-loss drugs like Wegovy, the net cost of the program “would be significant over the next 10 years.”
“It could lead to Medicare ending up paying for the drug to be used for weight loss purposes,” Gostin explained. “That would bankrupt Medicare and cause a taxpayer revolt.”
Juliette Cubanski, deputy director of the Medicare policy program at KFF, a nonpartisan group that studies public health policy issues, said that while Medicare will not cover the drug solely for weight loss, many people with heart disease have overweight or obesity.
“We could see Medicare patients with both conditions get coverage for this drug because of its heart health benefits,” Cubanski said. “That’s potentially a big thing given the high demand for this drug, even though there aren’t many insurers that will cover it.”
The drug would be paid for by Medicare Part D, which covers the cost of medications people take at home, the spokesperson said.
It’s unclear how private insurance companies that offer supplemental coverage for Part D will respond, Cubanski added, noting that plans have the ability to add new medications to the drug formulary for those who pay in the middle of the year, “but given the cost of this medicine, plans may not want to be the first to step forward.”
