Medicare New Rules May Extend Wegovy Coverage to 3.6 Million Americans

livewell
September 5, 2024
Noah Bennett

Introduction

Are you wondering about Medicare Wegovy coverage? In simple terms, Medicare now provides Wegovy coverage when you need it for cardiovascular diseases like heart attack or stroke. Earlier, Medicare did not cover this drug because most people take it for weight loss. However, the Food and Drug Administration (FDA) recently allowed its usage for cardiovascular problems. FDA has approved Wegovy (semaglutide) for reducing the risks of stroke and heart attack. This is why Medicare is going to start covering it in its plans.

Reports estimate that as many as 3.6 million people can benefit from Medicare Wegovy coverage. In this guide, we will explain what the Wegovy coverage under Medicare actually means. Besides, we’ll shed light on how you can use it for weight loss.

What is Wegovy?

The FDA recently cleared a new use for the popular weight loss drug Wegovy. This is to lower the risk of heart attacks and strokes in overweight or obese people who have heart problems. Wegovy is a GLP-1 (glucagon-like peptide-1) agonist, a medicine first allowed to treat type 2 diabetes. However, this drug is also very good at treating obesity. The new use of Wegovy makes it possible for Medicare and other insurance companies to pay for this drug.

Currently, the law doesn’t allow Medicare to pay for Wegovy or other drugs when used solely to treat obesity. But Medicare has been paying for semaglutide which patients use to treat diabetes. Since the formula for Wegovy is also semaglutide, the FDA-approval means people can use it for various purposes.

Medicare Coverage of Wegovy

The FDA’s decision to approve Wegovy has opened the doors for Medicare to cover this drug. Earlier, the FDA considered it an anti-obesity or weight loss drug. However, recent research reports highlighted its utility in treating cardiovascular problems and strokes.

No sooner had the FDA approved this drug than the Centers for Medicare and Medicaid Services (CMS) indicated its coverage. It noted that the Medicare Part D plan will provide Wegovy coverage for people with heart problems. Wegovy is a drug that patients can inject or administer themselves. Therefore, it is covered under Medicare Part D, which provides outpatient drug benefits. Medicare Part B will not cover this medication because it pays for doctor-administered drugs.

People who have had a heart attack, stroke, or peripheral artery disease in the past can use this medication. Moreover, people who are either obese or overweight may also take Wegovy for the first time. Based on a research report that analyzed 2020 Medicare statistics, about 7% of Medicare recipients, or 3.6 million people, had obesity or overweight and cardiovascular disease in 2020. This means that Medicare could cover Wegovy for its new indication. This number could be higher if research reports used more up-to-date data than the data used for this study.

Just over a quarter of Medicare recipients, or 26%, will be overweight or obese in 2020. These 3.6 million beneficiaries are part of that group. Now that the FDA has approved the new use of Wegovy, this can benefit these people. This could mean that one in four Medicare recipients who are overweight or obese can now get this drug.

This group of 3.6 million people also had diabetes (not Type 1). It’s possible that these people could have had Medicare coverage for GLP-1s as a treatment for diabetes. However, the new use of Wegovy will make it easier for diabetics to get Medicare coverage for this drug.

Why Some People May Not Benefit from Medicare Wegovy Coverage

After the FDA’s approval, Medicare has started providing Wegovy Coverage under its Part D plans. However, some people still may not be able to benefit from Wegovy coverage under Medicare. This can be one of the surprising cons of Medicare.

It’s not clear that everyone who is eligible because of the new indication will take Wegovy. Some people might not like the possible negative reactions and side effects. Besides, the out-of-pocket costs could also stop people from taking this drug. The drug’s list price is $1,300 a month. This amount does not include any rebates or other discounts that pharmacy benefit managers may have arranged.

Moreover, Medicare may provide Wegovy coverage by considering it as a specialty tier drug. This means that Part D plans can charge coinsurance of 25% to 33%. Medicare recipients who have to pay coinsurance may have to pay between $325 and $430 a month. It is before they reach the new limit on out-of-pocket drug spending set by the Inflation Reduction Act. This limit will be around $3,300 per year for brand-name drugs in 2024 and $2,000 per year in 2025.

A high number of people with Medicare live on low means. This is why they would still not be able to pay even $2,000 out of their own pockets. In the end, how much users have to pay out of pocket will depend on how well their Part D plan covers Wegovy.

Also, some people might have trouble getting Wegovy coverage for other reasons. That is if Part D plans to use tools like prior permission and step therapy to control the costs. These things might make Medicare recipients less likely to use it, even if they are in the target group. This is why not everyone can have Medicare benefits for Wegovy.

What’s Next

The government has started Wegovy coverage expansion. This is to ensure that more people have Wegovy access under Medicare. Some Medicare Part D plans have indicated that they will start providing Wegovy coverage this year. However, it is not clear how many people will get Medicare Wegovy coverage in 2024.

The FDA keeps approving (or disapproving) new drugs and their use for more conditions. That is why Medicare drug plans can add such drugs to their lists throughout the year. However, it is not a guarantee that Medicare plans pay for every new medication. Part D plans have to cover at least two drugs from each group and all or almost all drugs from six protected groups. For now, Wegovy has a high price and could have a lot of patients. For this reason, many Part D plans might not want to add more coverage right now. They can’t change their rates in the middle of the year to reflect the higher costs of using this drug. In 2025, it might be more possible that coverage will be wider.

Conclusion

In short, Wegovy is an important medication that you can use to treat heart problems, strokes, and weight loss. Previously, the FDA did not approve it because most people used it for weight loss purposes. Medicare does not cover any drug that is solely used for weight loss. However, in this years, the FDA has approved this drug because it reduces the risks of heart attacks and stroke. This has made Wegovy coverage under Medicare a reality. As a result, almost 3.6 million people can benefit from Wegovy coverage under Medicare. We can also call it Wegovy for Americans Medicare.

In this article, we have explained Wegovy coverage under Medicare as well as Medicare rules Wegovy.

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Is Wegovy and Ozempic covered by Medicare?

Medicare does not pay for any drug that is only used to lose weight. Medicare Part D covers the drug Ozempic only to treat diabetes, not to help people lose weight. In the same way, Medicare covers Wegovy to lower the chance of serious heart problems. But not as a way to lose weight.

What is the criteria for Wegovy to be covered by insurance?

For Medicare to provide Wegovy coverage, an individual needs to meet the following requirements. First, they have a high BMI (body mass index), which the FDA considers to be 30 or more. Second, when a person has a high risk of heart disease, attack, or stroke.

Will Medicare cover weight loss drugs?

By law, Medicare does not pay for prescription drugs that are only used to lose weight. However, you can get them under a Medicare plan if they are FD-approved for another health problem. For instance, Wegovy can reduce the risk of heart attacks and strokes, but it also helps reduce weight. So, you can get it under Medicare as it is FDA-approved.

Will Medicare cover Wegovy for high cholesterol?

No, Medicare does not cover drugs like Wegovy for controlling or treating high cholesterol. Because it is not a disease and you can control yourself. However, if high cholesterol leads to heart problems, Medicare can cover some related medications. Otherwise, you have to bear the costs of these medicines out of your pocket.

What is a cheaper version of Wegovy?

Wegovy is an expensive drug, and not everyone can afford it. A cheaper alternative is compounded semaglutide. This is because the main ingredient in both Wegovy and compounded semaglutide is the same. Some health care providers recommended compounded semaglutide for weight loss. This can be a cheaper alternative to Wegovy.