• Posted August 27, 2024

3.6 Million Americans Could Be Covered for Wegovy Under New Medicare Rules

New Medicare rules could make 3.6 million Americans -- or even more -- eligible for treatment with the pricey weight-loss drug Wegovy, a new study finds.

Under the new rules, the government will pay for Wegovy treatment if a person with high BMI also has heart disease.

Until now, federal regulations have restricted Medicare from covering drugs prescribed solely for weight loss, researchers noted.

For this study, researchers analyzed data from people 65 and older who took part in a federal health and nutrition survey between 2011 and 2020.

Maximum annual costs to Medicare could be as high as $34 billion if Wegovy is prescribed to all patients with high BMI and a history of heart attack, stroke, hardened arteries or chest pain, the data show.

Wegovy has a list price of about $1,350 for a 28-day supply, according to GoodRx.com.

But even if heart disease is more narrowly defined by federal regulators, covering Wegovy (semaglutide) looks to be a budget-buster for the Medicare program, researchers said.

Under a narrow definition of heart disease, “only 1 in 7 Medicare beneficiaries with elevated BMI are likely to be eligible to receive semaglutide, but costs to Medicare could still exceed $10 billion per year,” said lead researcher Dr. Alexander Chaitoff with the Brigham and Women’s Hospital Center for Healthcare Delivery Sciences.

The findings were published Aug. 26 in the Annals of Internal Medicine.

“In this conservative coverage scenario, that means most beneficiaries with elevated BMI and cardiovascular risk would remain ineligible for semaglutide, yet the medication could still potentially become one of the costliest drugs to Medicare,” Chaitoff said in a hospital news release.

More information

The University of California, Davis, has more about semaglutide for weight loss.

SOURCE: Brigham and Women’s Hospital, news release, Aug. 26, 2024