3.6 million Medicare patients could get heart health coverage

Medicare’s budget could be strained as more plans cover Wegovy’s costs. The program’s prescription drug plans could spend an additional $2.8 billion net if just 10% of the eligible population, or about 360,000 people, used the drug for a full year, according to KFF.

Under new guidance released in March, Medicare Part D plans can cover Wegovy for patients provided they are obese or overweight, have a history of heart disease and are specifically prescribed the injection weekly to reduce their risk of heart attack and stroke. The Food and Drug Administration approved Wegovy for this purpose in March.

KFF said this applies to 3.6 million, or 7%, of total beneficiaries, based on 2020 data. This group also represents 1 in 4 of the 13.7 million obese Medicare patients. or overweight. Those numbers could be higher based on more recent data, the nonprofit group said.

The analysis suggests that, for the first time, some Medicare beneficiaries will be able to access Novo Nordisk’s Wegovy without having to shoulder the full $1,300 monthly price tag on their own.

Notably, Medicare prescription drug plans administered by private insurers, known as Part D, currently cannot cover Wegovy and other GLP-1 drugs intended solely for weight loss. GLP-1s are a dynamic class of obesity and diabetes treatments that work by mimicking a hormone produced in the gut to suppress a person’s appetite and regulate their blood sugar.

But KFF’s analysis found that Medicare beneficiaries who take Wegovy could still face monthly costs of $325 to $430 if they had to pay a percentage of the drug’s list price for a month’s supply.

A new Part D cap on out-of-pocket spending would limit beneficiaries’ out-of-pocket spending to about $3,300 in 2024 and $2,000 in 2025. Yet these amounts pose a significant burden for those living on modest incomes.

Some patients may also have difficulty accessing Wegovy if Part D plans that decide to cover it implement certain requirements to control costs and ensure the drug is used appropriately. This could include “step therapy,” which requires plan members to try other medications or less expensive ways to lose weight before using a GLP-1 such as Wegovy.

“These factors could have a moderating effect on use by Medicare beneficiaries, even within the target population,” KFF wrote in its analysis.

Some Part D plans have already announced they will begin covering Wegovy this year, but it’s unclear how extensive the coverage will be. KFF said many plans may be reluctant to expand coverage now because they cannot adjust their premiums mid-year to account for higher costs associated with using the drug.

This means broader coverage in 2025 may be more likely, KFF added.

Medicare already covers GLP-1 and other diabetes treatments, like Novo Nordisk’s blockbuster Ozempic.

Among Medicare beneficiaries who are obese or overweight and have a history of heart disease, 1.9 million also have diabetes, according to KFF. This already makes them eligible for Medicare coverage for other GLP-1 drugs approved for this disease.

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Gn Health

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