In a brand new evaluation, KFF finds that 3.6 million folks with Medicare might be eligible for protection of Wegovy (semaglutide) now that the Meals and Drug Administration has accredited the usage of the anti-obesity drug to scale back the danger of coronary heart assaults and stroke in sure sufferers.
This alteration probably permits entry to Wegovy for simply over 1 in 4 of the 13.7 million folks on Medicare identified with weight problems or chubby, primarily based on knowledge from 2020, the evaluation reveals.
Primarily based on KFF analysis, about 7% of beneficiaries, or 3.6 million folks, had established heart problems and weight problems or chubby in 2020 and might be eligible for protection of Wegovy to scale back the danger of great coronary heart issues. (Amongst this group, 1.9 million additionally had diabetes, making them already eligible for Medicare protection of different GLP-1 medicine accredited for diabetes.)Â
Though Wegovy already had FDA approval as an anti-obesity treatment, Medicare is prohibited by legislation from overlaying medicine when prescribed for weight problems. The drug’s new approval by the FDA to be used to scale back coronary heart assaults and stroke paves the best way for Medicare to cowl it for these functions.
How this transformation impacts Medicare spending will rely partially on what number of Half D plans add protection for Wegovy and the extent to which plans apply restrictions on use like prior authorization, what number of eligible folks use the drug, and negotiated costs paid by plans. Assuming simply 10% of eligible beneficiaries use Wegovy in a given yr, and assuming a 50% rebate on the record worth, Medicare would incur almost $3 billion in extra web Half D spending for one yr for this one drug alone.
KFF additionally finds that beneficiaries who take Wegovy might face month-to-month out-of-pocket prices of $325 to $430 in the event that they should pay a share of the drug’s $1,300 record worth for a month’s provide. The brand new Half D cap on out-of-pocket spending would restrict beneficiaries’ out-of-pocket value to round $3,300 in 2024 and $2,000 in 2025—nonetheless important sums for many who reside on modest incomes.Â
It’s attainable that Medicare might choose semaglutide for drug worth negotiation as early as 2025, primarily based on its earliest FDA approval in late 2017, with a negotiated worth accessible starting in 2027. This might assist to decrease Medicare spending on Wegovy in addition to Ozempic, the model accredited for kind 2 diabetes. (Each the Half D out-of-pocket spending cap and Medicare drug worth negotiations have been established below the Inflation Discount Act of 2022.)
The total evaluation, and different knowledge and analyses about Medicare spending on pharmaceuticals, is on the market at kff.org.
