The Centers for Medicare and Medicaid Services (CMS) recently issued guidance regarding the coverage of anti-obesity medications, signaling a significant shift in policy. However, the Wegovy coverage applies only to cases where these medications are prescribed for treating conditions other than obesity.
Expanded Indication for Wegovy
The decision by CMS was influenced by the expanded indication of Wegovy, an anti-obesity medication recently approved by the Food and Drug Administration (FDA). Wegovy, also known as semaglutide, received FDA approval for reducing the risk of cardiovascular death, heart attack, and stroke in patients with both cardiovascular disease and obesity.
A spokesperson for CMS emphasized that the recent change in FDA-approved use for Wegovy has prompted the adjustment in coverage rules for Medicare Part D and Medicaid. The guidance issued by CMS specifies that anti-obesity medications receiving FDA approval for additional medically accepted indications may be considered for coverage under Medicare Part D plans, but only for those specific uses. It’s worth noting that medications approved solely for weight loss purposes do not fall under this consideration.
Historical Context
The decision marks a departure from longstanding Medicare policies that have prohibited coverage for weight loss treatments. This restriction originated from the Medicare Modernization Act of 2003, which was prompted by concerns regarding the safety of weight loss drugs available at the time, notably fenfluramine/phentermine, due to their associated dangerous side effects.
Efforts to expand coverage for obesity treatments under Medicare have gained momentum with the introduction of the Treat and Reduce Obesity Act in Congress. This legislation seeks to broaden coverage for healthcare providers, services, and drugs related to obesity management. Obesity medicine groups and pharmaceutical companies such as Novo Nordisk have actively advocated for the passage of this bill.
Also Read: Wegovy Granted New Approval Beyond Weight Loss
Wegovy’s Mechanism and Efficacy
Wegovy belongs to a newer class of drugs called GLP-1 agonists, which mimic a gut hormone to stimulate insulin production and suppress appetite. Clinical trials involving 17,600 participants across multiple countries demonstrated Wegovy’s effectiveness in reducing the risk of major adverse cardiovascular events by 20%.
While the decision to expand coverage for anti-obesity medications represents a significant development, it comes with limitations tied to specific indications approved by the FDA. As legislative efforts continue to evolve and new medications enter the market, the landscape of obesity treatment coverage under Medicare may undergo further changes, potentially offering broader access to effective therapies for patients managing obesity-related conditions.
