Medicare to cover Wegovy to prevent strokes and heart attacks
Incredible news out of Washington, D.C. Medicare Part D now covers Wegovy when a doctor prescribes it to prevent heart attacks and strokes. The U.S. Food and Drug Administration (FDA) just approved an additional “indication” for Wegovy due to its ability to reduce the risk of life-threatening cardiac events in obese/overweight adults who also have known heart disease.
SELECT phase 3 trials sealed the deal
Manufacturer Novo Nordisk says the SELECT phase 3 trials (Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity) made this change to Medicare guidelines possible. Launched in 2018 in 41 countries, these trials looked at Wegovy use and cardiovascular outcomes in 17,604 adults with obesity and known heart disease. Read more about the SELECT trials in The New England Journal of Medicine.
This is the first time Medicare approved coverage for a GLP-1 drug
The Medicare Modernization Act of 2003 is the mechanism that blocks Medicare and Medicaid from covering weight loss drugs. At the time, government officials feared potential weight loss drug side effects — especially from medications such as phentermine. But now this rule also prevents coverage of all GLP-1 treatments.
So, this is the first time Medicare approved a GLP-1 drug, best known for treating Type 2 diabetes and/or obesity, for coverage. While this is exciting – and hopefully the first step in Medicare loosening its stance on GLP-1 medications – it won’t help everyone who suffers from obesity.
Does Medicare pay for Wegovy?
In order for a doctor to prescribe Wegovy – and for Medicare Part D – to cover it, the drug must be used explicitly to lessen the possibility of heart attack and stroke. Your doctor must document your cardiovascular disease paired with a weight that puts you in the obese or overweight category. Your doctor may also have to submit a prior authorization (PA) before coverage is approved.
If you are on Medicare (or a state-run Medicaid plan) and are obese or overweight, but do not have existing cardiovascular risks, you will not be approved for Wegovy coverage at this time.
Paying out of pocket for Wegovy
Medicare Part D recipients who want to take Wegovy (without having existing heart issues) must pay out of pocket – and that’s an expensive commitment. A one-month supply of Wegovy costs $1,349 retail. And while manufacturer Novo Nordisk does offer a savings card, Medicare recipients aren’t allowed to use it.
If you’re in this boat and do want to take a GLP-1 medication to reduce your weight, you can also consider Zepbound (tirzepatide) at $1,060 per month or Saxenda (liraglutide) at $1,349.
Or, look into a compounding pharmacy that sells GLP-1 compounds at a reduced cost.
How to lobby for the expansion of Medicare to include weight-loss drugs
Now is the time to reach out to your U.S. senators and congressional representatives and tell them to support the Treat and Reduce Obesity Act of 2023 (TROA). This is H.R.4818 in the House and S.2407 in the Senate.
Here’s what TROA will do, according to text in the bill:
“This bill expands Medicare coverage of intensive behavioral therapy for obesity. Specifically, the bill allows coverage for therapy that is provided by
- (1) a physician who is not a primary care physician;
- or (2) other health care providers (e.g., physician assistants and nurse practitioners) and approved counseling programs, if provided upon a referral from, and in coordination with, a physician or primary care practitioner.
Currently, such therapy is covered only if provided by a primary care practitioner.
The bill also allows coverage under Medicare’s prescription drug benefit of drugs used for the treatment of obesity or for weight loss management for individuals who are overweight.”Use the Obesity Action Committee’s online tool to find your state senators and representatives. Then use the OAC’s sample letter to contact them and lobby for their support of H.R.4818 (House bill) and S 2407 (Senate version).
The wrap-up
Let me know if you write to your senators and congressional reps. I’d love to know if they support the bill or not and why. Email me or post about it on the Shots to Shed Pounds Facebook page.
Featured image courtesy of Novo Nordisk, maker of Wegovy.
