Key TakeawaysMedicare now covers the injectable anti-obesity drug Wegovy for reducing cardiovascular risks in patients with heart disease and obesity, following its FDA approval for this specific use.Despite the broader availability of Wegovy, Medicare’s coverage for anti-obesity medications remains limited to those with additional medically accepted indications, due to longstanding legislative restrictions.The high cost of anti-obesity drugs and the uncertain impact on overall healthcare spending are major barriers to expanding Medicare coverage for these medications.
Key Takeaways
Medicare now covers the injectable anti-obesity drug Wegovy for reducing cardiovascular risks in patients with heart disease and obesity, following its FDA approval for this specific use.Despite the broader availability of Wegovy, Medicare’s coverage for anti-obesity medications remains limited to those with additional medically accepted indications, due to longstanding legislative restrictions.The high cost of anti-obesity drugs and the uncertain impact on overall healthcare spending are major barriers to expanding Medicare coverage for these medications.
By law, Medicare doesn’t cover any weight loss or anti-obesity drugs. But one Food and Drug Administration (FDA) indication at a time, that could start to change.
In March, the FDA approved Wegovyto reduce the risk of heart attack, stroke, and other cardiovascular problemsin adults with heart disease who have obesity or overweight. The injectable medication, part of a class of drugs called glucagon-like peptide (GLP-1) receptor agonists, was previously approved just for weight management.
The heart disease indication means Medicare Part D plans can cover the drug.
Now, pharmaceutical companies are researching other conditions that obesity medications can treat in order to earn more FDA indications, potentially expanding insurance coverage. In April, for instance, Eli Lilly announced study results demonstrating Zepbound significantlyimproved symptoms of obstructive sleep apnea.
Ozempic May Help Treat Conditions Beyond Diabetes and Obesity
Why Doesn’t Medicare Cover Obesity Medication?
While some other insurers will cover anti-obesity drugs without an additional “medically accepted condition,” the Medicare Modernization Act of 2003 still prohibits it. Medicare Part D and Medigap plans are also unlikely to cover them.
It’s not just the injectable anti-obesity drugs that Medicare doesn’t cover; plans also don’t cover older oral weight management drugs such as Xenical. These medications don’t help people lose weight quite as quickly as GLP-1s like Wegovy or Zepbound, but they’re still very effective,Dina Griauzde, MD, an obesity specialist at Michigan Medicine, told Verywell.
The real reason for the coverage delay, experts say, is concern over how much it will cost the healthcare system.
Ways to Save on Mounjaro and Ozempic
CBO pegged the monthly out-of-pocket cost of semaglutide (the active ingredient in Ozempic, Wegovy, and Rybelsus) at $1,349 per month, which would be over $16,000 a year for a consumer.
“Medicare’s coverage of AOMs at their current prices…would increase overall federal spending,” CBO said. That could result in higher premiums—the monthly amount Medicare recipients pay for their plans.
While the Congressional Budget Office said it will continue to examine how much anti-obesity medications will cost or save Medicare in the long run, it is not currently aware of research that suggests the drugs will improve health outcomes enough to decrease healthcare spending for related conditions.
Other Ways to Access GLP-1 Drugs
If you don’t have a diabetes diagnosis but you and your primary care doctor believe you are a good candidate for a GLP-1 medication, consider taking an A1C blood test, an American Diabetes Association spokesperson told Verywell. Almost three million Americans are living with undiagnosed diabetes, half of whom have overweight. If the test confirms you have diabetes, you’ll have a better chance of getting coverage for medication—which might also help manage your weight.
What This Means For YouIf you have obesity or overweight and heart disease, the new Medicare coverage for Wegovy might offer you a valuable treatment option. It’s important to discuss with your healthcare provider whether this medication could be suitable for you. More indications for GLP-1 drugs are on the horizon, which means more insurance coverage may be, too.
What This Means For You
If you have obesity or overweight and heart disease, the new Medicare coverage for Wegovy might offer you a valuable treatment option. It’s important to discuss with your healthcare provider whether this medication could be suitable for you. More indications for GLP-1 drugs are on the horizon, which means more insurance coverage may be, too.
2 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Santilli M, Manciocchi E, D’Addazio G, et al.Prevalence of obstructive sleep apnea syndrome: a single-center retrospective study.Int J Environ Res Public Health. 2021;18(19):10277. doi:10.3390/ijerph181910277UpToDate.Glucagon-like peptide 1 receptor agonists for the treatment of type 2 diabetes mellitus.
2 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Santilli M, Manciocchi E, D’Addazio G, et al.Prevalence of obstructive sleep apnea syndrome: a single-center retrospective study.Int J Environ Res Public Health. 2021;18(19):10277. doi:10.3390/ijerph181910277UpToDate.Glucagon-like peptide 1 receptor agonists for the treatment of type 2 diabetes mellitus.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Santilli M, Manciocchi E, D’Addazio G, et al.Prevalence of obstructive sleep apnea syndrome: a single-center retrospective study.Int J Environ Res Public Health. 2021;18(19):10277. doi:10.3390/ijerph181910277UpToDate.Glucagon-like peptide 1 receptor agonists for the treatment of type 2 diabetes mellitus.
Santilli M, Manciocchi E, D’Addazio G, et al.Prevalence of obstructive sleep apnea syndrome: a single-center retrospective study.Int J Environ Res Public Health. 2021;18(19):10277. doi:10.3390/ijerph181910277
UpToDate.Glucagon-like peptide 1 receptor agonists for the treatment of type 2 diabetes mellitus.
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