Medicare plans can cover Wegovy for patients with heart conditions

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Medicare plans can cover the popular weight-loss drug Wegovy to treat seniors with a history of cardiovascular disease, officials said Thursday, a move that could substantially expand access to the blockbuster drug for certain adults.

Until now, seniors participating in federal prescription-drug programs could not be covered for Wegovy, made by Novo Nordisk, because of a federal law that excludes anti-obesity medications from coverage. The shift follows a decision by the Food and Drug Administration this month that broadened the approved use of Wegovy to include reducing the risk of heart failure, effectively treating it as more than a weight-loss drug.

The FDA expanded Wegovy’s regulatory label after a clinical trial last year found that the drug reduced the risk of heart problems for overweight people by 20 percent.

As a result, Medicare Part D drug-benefit plans — administered by private companies — can cover Wegovy to reduce the risk of heart failure in overweight patients with a history of cardiovascular disease, according to a spokesperson for the Centers for Medicare and Medicaid Services. But the drug generally would not be covered for weight management alone, the spokesperson said in a statement.

The new policy would apply to all anti-obesity drugs that receive FDA approval for what CMS calls “an additional medically accepted indication” — like reducing the risk of heart failure. Wegovy is the first such drug to receive FDA approval for that purpose, and analysts expect that at least some Medicare Part D plans will cover it.

“CMS is committed to ensuring that people have access to treatments and treatment options that improve health outcomes,” the agency said.

“We are encouraged to see the recent guidance by CMS,” Novo Nordisk said in a statement, adding that “there’s more work to be done” because Wegovy still can’t be covered by Medicare when used only for managing weight.

Broadening insurance coverage is another milestone for Wegovy, which, like its diabetes drug cousin Ozempic, has become a cultural sensation and blockbuster. The move by CMS could also add pressure on commercial insurers to cover the pricey drug, according to researchers and Wall Street analysts.

Wegovy works by mimicking a naturally occurring hormone called glucagon-like peptide 1, or GLP-1, that slows the emptying of the stomach and sends a signal of fullness to the brain. It has proved so popular that Novo Nordisk has struggled to keep up with demand, leading the FDA to declare the drug in shortage and prompting the drugmaker to take extraordinary steps to boost production.

Still, the high cost of the drug has made some insurers and employers reluctant to cover it, and Medicare plans may wrestle with the same considerations. KFF, a health-policy research organization, cited a recent study that found just 10 percent of Medicare beneficiaries using Wegovy would cost the federal program about $13.6 billion.

“This could be a selling point for plans that decide to cover it. There’s a lot of demand for these medications,” said Juliette Cubanski, deputy director of KFF’s Medicare policy program, referring to how private Medicare plans seek to attract seniors. “On the other hand, it is still a relatively expensive medication.”

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