Biotech
Wednesday, April 24th, 2024 2:13 pm EDT
Key Points
- Over 3 million Medicare beneficiaries could qualify for coverage of Wegovy now that it’s approved for heart health, potentially easing the financial burden of the drug’s high cost.
- Despite eligibility, some beneficiaries might still face out-of-pocket expenses as certain Medicare prescription drug plans delay coverage until 2025, potentially straining Medicare’s budget if more plans cover Wegovy.
- New guidance allows Medicare Part D plans to cover Wegovy for obese or overweight patients with a history of heart disease, potentially benefiting around 3.6 million beneficiaries. However, out-of-pocket costs, coverage restrictions like step therapy, and plan reluctance to expand coverage until 2025 could hinder accessibility for some Medicare beneficiaries, despite the drug’s potential health benefits.
More than 3 million people enrolled in Medicare could potentially benefit from coverage of the weight loss drug Wegovy, now that it’s approved in the U.S. for heart health as well, according to an analysis by the Kaiser Family Foundation (KFF). However, some eligible beneficiaries might still encounter out-of-pocket costs for this expensive drug, as certain Medicare prescription drug plans may delay coverage until 2025. The adoption of Wegovy by more Medicare plans could strain the program’s budget, with estimates suggesting an additional net spending of $2.8 billion if 10% of the eligible population, around 360,000 individuals, use the drug for a full year. New guidance issued in March allows Medicare Part D plans to cover Wegovy for patients who are obese or overweight, have a history of heart disease, and are prescribed the drug specifically to reduce the risk of heart attacks and strokes. This applies to roughly 7% of total beneficiaries, representing 1 in 4 of the 13.7 million Medicare patients who are obese or overweight. Despite this, certain beneficiaries might still face monthly out-of-pocket costs ranging from $325 to $430, depending on factors like plan design and pricing structure. While a new Part D cap on out-of-pocket spending aims to limit costs, it may still pose a significant financial burden for those on modest incomes. Moreover, some beneficiaries could encounter barriers to accessing Wegovy if Part D plans impose requirements like step therapy, which mandates trying lower-cost medications before resorting to more expensive options like Wegovy. Although some plans have announced coverage of Wegovy this year, broader coverage may be delayed until 2025 due to concerns about adjusting premiums mid-year to accommodate higher costs associated with the drug. Despite these challenges, Medicare already covers other GLP-1 drugs, like Novo Nordisk’s Ozempic, for diabetes treatment, suggesting a potential pathway for broader coverage of Wegovy in the future for eligible beneficiaries.
For the full original article on CNBC, please click here: https://www.cnbc.com/2024/04/24/wegovy-3point6-million-medicare-patients-could-get-heart-health-coverage.html
