Wegovy’s New Heart Indication to Expand Medicare Coverage for 3.6M Beneficiaries: KFF

 An estimated 3.6 million Medicare beneficiaries may now be eligible for coverage of Novo Nordisk’s Wegovy (semaglutide), according to an analysis released by the Kaiser Family Foundation on Wednesday. 

The expanded coverage is thanks to the FDA’s recent approval of the use of Wegovy to reduce the risk of heart attack and stroke in people with cardiovascular disease who are already obese. Using data from 2020, the approval opens access to Wegovy for one in four Medicare beneficiaries with obesity, the Kaiser Family Foundation (KFF) finds. 

GLP-1 injectables such as Wegovy have already taken the obesity treatment market to all-time highs, despite a lack of coverage by the Centers for Medicare and Medicaid Services (CMS) under the obesity indication. For now, obesity is excluded from Medicare coverage by law. The list price of Wegovy is right at $1,350 for a four-week supply.  Novo offers discount programs to lower costs, but these programs are not accessible for Medicare and Medicaid beneficiaries.  

CMS has already approved Wegovy to be covered under its Part D plans with the addition of its “medically accepted indication.” Some Part D plans have announced coverage will begin this year for Wegovy, though it's not yet clear how extensive the coverage will be in 2024.  

The GLP-1 injection may be covered as a specialty tier drug, for which Part D plans are able to charge a coinsurance of 25% to 33%, or $325 to $430, before reaching the $3,300 new annual out-of-pocket cap established by the Inflation Reduction Act. The cap will lower to $2,000 in 2025, both limits based on name brand drugs only. 

Assuming plans receive a 50% rebate on the list price and 10% of the target population use the drug for a full year, KFF’s analysis pegged Medicare Part D spending at $2.8 billion for one year on this drug alone. Wegovy is the label name of Novo’s previously approved diabetes drug Ozempic.  

Because Ozempic was approved in 2017, the seven-year time limit is almost up to allow CMS to select the drug for price negotiation as early as 2025. Ozempic was sixth among the 10 top-selling drugs covered by Medicare Part D. 

With the laundry list of comorbidities for obesity, GLP-1 drugs are a tool that can have a major impact beyond weight loss. In addition to Novo’s evidence of lowering cardiovascular risk, another recent study from Eli Lilly showed its GLP-1 tirzepatide alleviated sleep apnea symptoms, reducing patients’ mean apnea-hypopnea index up to 63%.  

GLP-1 demand is surging. In 2023, the drug type made up for nearly half of expenditures in the endocrine drug class at over $63 billion, according to STAT News.  

https://www.biospace.com/article/wegovy-s-new-heart-indication-to-expand-medicare-coverage-for-3-6m-beneficiaries-kff-/