Medicare plans can now cover Wegovy for patients at risk of heart disease

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Wegovy, a semaglutide medication, will be covered by Medicare. / Bloomberg via Getty Images

For the first time, Medicare will allow coverage of one of the new blockbuster weight-loss drugs for enrollees in Part D plans.

The plans may now cover Wegovy when prescribed to prevent heart attacks and strokes, according to a new policy issued this week from the Centers for Medicare and Medicaid Services.

Wegovy is a GLP-1 agonist, a class of obesity drugs promising a sea change in weight loss. They act on hormones and the brain to drastically reduce appetite, among other things.

But Medicare is prohibited from paying for weight-loss treatments so seniors have had to pay out of pocket for the drugs or use supplemental insurance. In early March, the Food and Drug Administration expanded the approval of Wegovy to say the drug can be used to reduce the risk of cardiovascular death, heart attack and stroke in people with cardiovascular disease and either overweight or obesity.

In clinical trials, Wegovy was found to reduce risks of cardiovascular events by 20% in higher weight patients.

That finding prompted CMS to change its Medicare Part D drug program to cover Wegovy, although it noted that this applies only for those patients struggling with both weight and heart disease. In other words, the injections, which can cost well over $1,000 a month out of pocket, will not be covered for enrollees only seeking to lose weight.

The new guidance also applies to state Medicaid plans, which also would be required to cover Wegovy for patients with both higher weight and heart disease risk.

Obesity doctor Angela Fitch says that the move to cover it even for a limited subset of patients is still significant. She's president of the Obesity Medicine Association, a group that advocates for treatment.

"It's certainly a big step forward, compared to no coverage at all," she says. "At least now we'll have coverage for those people who have a known history of heart disease," she says. "So hopefully that will trickle down into covering it for everybody with overweight and obesity."

And, Fitch notes, Medicare sets the standard for coverage in insurance generally, so this move could ultimately affect more patients. "My hope would be that commercial insurance would follow."

In a statement, a CMS spokesperson said: "CMS is committed to ensuring that people have access to treatments and treatment options that improve health outcomes."

The Medicare guidance could also expand the use of other similar medicines. It states that anti-obesity medications that receive FDA approval for an additional condition other than weight-management alone, can be considered a Part D drug for that specific use. For example, if one of the drugs receives FDA approval to treat diabetes or prevent cardiovascular disease, Medicare part D plans may cover it for that use.

However CMS specified they may also require prior authorizations to ensure that is being used only for the approved use.

In a statement, Wegovy's maker Novo Nordisk said it was "encouraged" by the new guidance from CMS but said it hopes to see Part D coverage expanded for "obesity medicines when used for chronic weight management."

The drug maker is among those pushing for Congress to expand coverage of treatments for obesity.