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  • Writer's pictureStaff @ LPR

Medicare and Medicaid open coverage of anti-obesity drugs for heart patients

Originally written by Zachary Brennan at End Points News.


The Centers for Medicare and Medicaid Services said that anti-obesity drugs should be covered for patients getting them for additional medical conditions, a move that could meaningfully expand access for patients in the US government health programs.

 

A CMS spokesperson told Endpoints News that the centers have issued guidance to Medicare Part D plans stating that anti-obesity medications with FDA approval for an additional medically accepted indication, such as reducing the risk of major cardiovascular events, can be covered for that use.

 

The programs are still prohibited from covering the drugs for the treatment of obesity alone. But many people with obesity have other conditions as well, and Wegovy and a competing drug from Eli Lilly are both being studied in multiple new indications, ranging from heart health to joint damage. Earlier this month, the FDA expanded Wegovy’s label to allow its use for the prevention of cardiovascular events.


“If this same drug also receives FDA approval to treat diabetes or reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight, then it would be considered a Part D drug for those specific uses only,” the CMS spokesperson said. The Wall Street Journal first reported the change.

 

Congressional efforts are also underway to add weight loss as an indication that CMS must cover.

 

Juliette Cubanski, deputy director of the Program on Medicare Policy at the health policy research group KFF, described the move as a “turning point” for GLP-1s, but cautioned that it wasn’t clear whether all health plans in the program would actually add the coverage.

 

“I would expect plans to impose prior authorization requirements to ensure that use does not expand beyond the population indicated in this new approval,” Cubanski said. “Plans will want to make sure they are paying for Wegovy only when it is being used by people with cardiovascular disease and obesity and only as a cardiovascular treatment, not when it is being used only as a treatment for weight loss.”

 

CMS also made clear that if a drug receives approval for an additional medically accepted indication during a contract year, Part D plans may include such drugs on their current formularies as they can be covered under Part D for that use.

 

“Part D plans may consider using prior authorization for these products to ensure they are being used for a medically accepted indication,” the CMS spokesperson said.

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