“Medicare $10 Billion Coverage of Semaglutide Weight Loss Treatment”.
medicare semaglutide weight loss coverage
Should Medicare Part D adopt a restrictive definition of cardiovascular disease, a substantial portion of patients would remain disqualified, even as new federal expenditures could surpass $10 billion.
Recent research delves into Medicare’s decision to cover semaglutide, highlighting that a stringent definition of cardiovascular disease might curtail eligibility, yet still drive annual costs beyond $10 billion. This scenario could render semaglutide one of Medicare’s priciest medications.
Semaglutide: Eligibility and Cost Projections
Current federal laws bar Medicare from covering medications prescribed solely for weight management. However, in March 2024, Medicare extended coverage to semaglutide (Wegovy), a widely-used glucagon-like peptide-1 receptor agonist (GLP-1RA), for patients with elevated body mass index (BMI) and confirmed cardiovascular disease (CVD).
The precise definition of “established CVD” has not been codified, yet it is poised to significantly influence both public health outcomes and Medicare expenditures.
A novel study, spearheaded by researchers from Brigham and Women’s Hospital, a key member of the Mass General Brigham healthcare network, estimates that approximately 3.6 million Medicare beneficiaries could become eligible for semaglutide.
The study also forecasts eligibility and potential maximum costs under varying definitions of cardiovascular risk, with findings published on August 26 in Annals of Internal Medicine.
Financial Impact of Restrictive Coverage
The research team scrutinized data from individuals aged 65 and older, or those on Medicare, who participated in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2020.
The findings suggest that if all patients with elevated BMI and a history of heart attack, stroke, coronary artery disease, or angina were treated with semaglutide, Medicare’s annual costs could soar to $34.3 billion after rebates.
“When cardiovascular disease is narrowly defined, only 1 in 7 Medicare beneficiaries with elevated BMI are likely to qualify for semaglutide, yet the cost to Medicare could still exceed $10 billion per year,” stated lead author Dr. Alexander Chaitoff, MD, MPH, of the Center for Healthcare Delivery Sciences in the Division of Pharmacoepidemiology at BWH.
“In this conservative coverage scenario, most beneficiaries with elevated BMI and cardiovascular risk would remain ineligible for semaglutide, yet the drug could still emerge as one of the most expensive in Medicare’s portfolio.”
For further details on this research, see A Diet Drug Dilemma for Medicare With a $145 Billion Price Tag.
Reference
“Estimating New Eligibility and Maximum Costs of Expanded Medicare Coverage of Semaglutide for Cardiovascular Risk Prevention” by Alexander Chaitoff, MD, MPH, Liam Bendicksen, BA, William B. Feldman, MD, DPhil, MPH, Alexander R. Zheutlin, MD, MS, and Hussain S. Lalani, MD, MPH, MSc, August 26, 2024, Annals of Internal Medicine. DOI: 10.7326/ANNALS-24-00308
Alongside Chaitoff, the BWH authors include Liam Bendicksen, William Feldman, and Hussain Lalani. Additional contributors include Alexander Zheutlin.
Although unrelated to this particular work, Alexander Chaitoff and William Feldman disclose consulting roles with Alosa Health, an academic detailing nonprofit focusing on older adult health. Dr. Lalani serves as a medical officer at the Center for Medicare and Medicaid Innovation. The views expressed here do not reflect those of the Federal government.
