Medicare Extends Coverage to Obesity Drug: 1 In 7 Beneficiaries May Qualify

If Medicare Part D were to implement a narrow definition of cardiovascular disease, a large number of patients could still be classified as ineligible, despite the fact that new federal spending could exceed $10 billion (1^✔ ✔Trusted Source
Estimating New Eligibility and Maximum Costs of Expanded Medicare Coverage of Semaglutide for Cardiovascular Risk Prevention

Go to source). Current federal regulations prohibit Medicare from providing coverage for medications prescribed exclusively for weight management. However, in March 2024, Medicare declared that it would broaden its coverage to include semaglutide (Wegovy), a widely used glucagon-like peptide-1 receptor agonist (GLP-1RA), for patients with a high body mass index (BMI) who also have diagnosed cardiovascular disease (CVD).

This development implies that the interpretation of "established CVD," which has yet to be formally defined, will significantly influence both public health outcomes and Medicare expenditures.

A recent study conducted by researchers at Brigham and Women’s Hospital, part of the Mass General Brigham healthcare system, estimates that approximately 3.6 million Medicare beneficiaries may qualify for semaglutide. The research also evaluates eligibility and potential maximum costs under various definitions of cardiovascular risk. The results are published in the Annals of Internal Medicine.

Eligibility Criteria Impacts Medicare Beneficiaries, Yet Increases Cost for Medicare

The research team analyzed data from respondents over 65 or who were on Medicare and who took part in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2020.

They found that if all patients with elevated BMI and history of heart attack, stroke, coronary artery disease, or angina were treated with semaglutide, maximum annual costs to Medicare could be as high as $34.3 billion after rebates.

“When established cardiovascular disease is narrowly defined, only 1 in 7 Medicare beneficiaries with elevated BMI are likely to be eligible to receive semaglutide, but costs to Medicare could still exceed $10 billion per year,” said lead author Alexander Chaitoff, MD, MPH, of the Center for Healthcare Delivery Sciences in the Division of Pharmacoepidemiology at BWH. “In this conservative coverage scenario, that means most beneficiaries with elevated BMI and cardiovascular risk would remain ineligible for semaglutide, yet the medication could still potentially become one of the costliest drugs to Medicare.”

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The broadening of Medicare coverage to include anti-obesity medications will be a significant milestone in the fight against obesity in the United States. Even if one in seven beneficiaries qualify for these treatments, this initiative will positively impact the lives of millions.

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