Medicare Part D to Cover Wegovy for Obese Patients at-risk for Heart Disease

Wegovy © Tobias Arhelger - stock.adobe.com

Following the FDA’s Mar. 8 decision to approve semaglutide (Wegovy) as a preventive for stroke and heart disease in overweight individuals, the CMS announced last week that it will soon be covered under their Medicare Part D drug program as well, multiple news outlets report.

“This patient population has a higher risk of cardiovascular death, heart attack and stroke," John Sharretts, M.D., director of the Division of Diabetes, Lipid Disorders, and Obesity in the FDA’s Center for Drug Evaluation and Research said in an FDA news release. "Providing a treatment option that is proven to lower this cardiovascular risk is a major advance for public health."

However, health plans may still require Medicare beneficiaries to undergo step therapy with other drugs before receiving a Wegovy prescription.

Marijane Hynes, M.D. is a clinical professor of Medicine at the George Washington Weight Loss Clinic in Washington, D.C. Almost half of the patients she serves are on Medicare or Medicaid.

“It is excellent that Medicare will cover Wegovy for CVD disease, as it will improve patient outcomes and help decrease cost and hospitalizations overall for patients with heart disease,” Hynes said.“However, this is secondary prevention, and Medicare needs to consider covering these medications for primary prevention when patients have obesity before they get heart disease.”

Without coverage, out of pocout-of-pocketket costs for Wegovy are around $1,400 a month, causing patients to seek cheaper options from Mexico and Canada. Gastric bypass surgeries are also extremely expensive without coverage – nearly $20,000 Hynes said.

Hynes also said that there is no “magic pill” or procedure that will make the weight melt away and stay away. She said there must be behavioral skills and an exercise regimen in place in addition to treatment.

There are also side effects that come along with Wegovy that patients should know about. Wegovy works by making fatty foods taste less appealing and can make patients sick if they decide to eat them after taking a dose.

“They're still injectable medications and someone has to be monitoring the patients and helping them through the side effects,” Hynes said.

Wegovy was first approved for chronic weight management in adults in June 2021. The approval was later expanded to include children ages 12 and older.