High BMI Eligibility for Semaglutide Raises Medicare Costs

61% of Medicare-eligible adults have a BMI of 27 or higher, indicating they could potentially benefit from a GLP-1 receptor agonist like semaglutide for weight loss (1^✔ ✔Trusted Source
Estimating New Eligibility and Maximum Costs of Expanded Medicare Coverage of Semaglutide for Cardiovascular Risk Prevention

Go to source). The number of patients eligible for semaglutide under the new Medicare Part D plan guidelines, which require a diagnosis of established cardiovascular disease (CVD), will depend on how CVD is defined. However, if eligibility extends to any beneficiary with elevated cardiovascular risk, Medicare could incur up to $145 billion in additional annual costs. These findings are published in the Annals of Internal Medicine.

Semaglutide Eligibility and Risk Factors Among Medicare Beneficiaries

Researchers from Brigham and Women’s Hospital, Harvard Medical School, and Northwestern University examined NHANES (National Health and Nutrition Examination Survey) between 2011 and 2020 to the Medicare beneficiaries who are most likely to be newly eligible for semaglutide based on SELECT trial criteria. They also describe which beneficiaries had any increased risk for future cardiac events and could be eligible pending future evidence generation and Part D coverage decisions.

The researchers then estimated the maximum cost to Medicare Part D that would arise from providing coverage to these various groups of patients by multiplying the number of newly eligible Medicare beneficiaries by the annual net price of semaglutide, generated by subtracting a 41% average discount from the manufacturer list price of the medication in March 2024.

The data showed that approximately 61% of Medicare-eligible adults with complete data had obesity and would potentially benefit from semaglutide for its weight loss benefits. However, when established cardiovascular disease is defined narrowly as in the SELECT trial, only 1 in 7, or 3.6 million people, would be likely to be newly eligible for semaglutide.

Alternatively, if a more liberal definition of established CVD risk were used by Part D plans, then 15.2 million people would be eligible. Even in the most likely scenario where conservative definitions of CVD are used and many people do not stay on semaglutide long-term, Medicare spending could increase by $10 billion annually.

The authors note that the analysis estimates maximum budgetary impacts but is not a spending projection and does not account for future payment reforms via the Inflation Reduction Act.

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Reference:

1. Estimating New Eligibility and Maximum Costs of Expanded Medicare Coverage of Semaglutide for Cardiovascular Risk Prevention - (https://www.acpjournals.org/doi/10.7326/ANNALS-24-00308)

Source-Eurekalert