Medicare would cowl pricey weight reduction medicine below Biden plan.
The Biden administration Tuesday introduced plans to offer protection for a category of pricey anti-obesity drugs together with Wegovy and Zepbound for these enrolled in Medicare and Medicaid.
Medicare, the federal well being program for adults 65 and older, has been prohibited by regulation from masking weight reduction medicine for older Individuals who’re overweight however should not have diabetes or coronary heart illness.
Below a rule proposed by the U.S. Division of Well being and Human Providers, the Biden administration estimates that 3.4 million Individuals on Medicare could be eligible for the medicine starting in 2026, which may retail for over $1,000 a month. Whereas some states at present cowl weight problems medicine for Medicaid enrollees, most don’t. The proposed rule would make an estimated 4 million Medicaid recipients eligible for protection.
Facilities for Medicare & Medicaid officers estimated the anti-obesity medicine would price Medicare and Medicaid about $40 billion over a decade. States could be anticipated to pay for about $3.8 billion of that complete quantity for Medicaid enrollees.
CMS officers acknowledged the proposed rule, which requires a prolonged means of amassing public feedback and assessment, would should be finalized after President-elect Donald Trump takes workplace subsequent yr. Trump has nominated Robert F. Kennedy Jr. to steer HHS, and Kennedy has mentioned in media interviews that he needs Individuals to concentrate on their diets somewhat than counting on remedy.
Individuals have struggled to afford the blockbuster class of weight reduction drugs known as GLP-1, or glucagon-like peptide-1, receptor agonists. The medicine have been first used to deal with diabetes however drugmakers have launched newer manufacturers reminiscent of Wegogy and Zepbound accredited for individuals with weight problems.
“It is a large optimistic step on the a part of the White Home and CMS to make sure that Medicaid and Medicare enrollees, who usually disproportionately face the brunt of weight problems, will obtain protection for anti-obesity drugs,” mentioned Dr. Fatima Cody Stanford, an weight problems drugs specialist at Massachusetts Normal Hospital and Harvard Medical Faculty in Boston.
The medicine are costly. For instance, the listing worth for Novo Nordisk’s weight reduction drug Wegovy is $1,349 month-to-month. By comparability, the drug sells for $186 in Denmark, $140 in Germany, and $92 in the UK, in line with paperwork introduced throughout a Senate Committee on Well being, Training, Labor and Pensions listening to in September.
Throughout the September listening to, Senators grilled the highest govt of Novo Nordisk about why the Danish firm prices Individuals much more for Wegovy and the diabetes drug Ozempic than it does sufferers in Europe.
Employers who present medical insurance advantages for employees and personal insurance coverage corporations largely cowl diabetes medicine reminiscent of Ozempic.
Ozempic and Wegovy, from Novo Nordisk, are primarily based on the GLP-1 drug semaglutide, although Wegovy is usually given at the next dose. Zepbound and the diabetes drug Mounjaro are each made by Eli Lilly and are primarily based on the drug tirzepatide, which is each a GLP-1 and has a second mode of motion that seems to make them much more efficient for weight reduction.
A survey shared final week by the advantages marketing consultant Mercer mentioned 44% of all massive employers this yr coated GLP-1 medicine for weight problems, up from 41% final yr.
The Biden administration officers didn’t instantly say how a lot it might price taxpayers to increase protection of the burden loss remedy to hundreds of thousands of Individuals. Biden administration officers mentioned weight problems drug protection would slash out-of-pocket prices for Medicare enrollees in search of these prescribed drugs by as much as 95%.
Earlier this yr, North Carolina’s medical insurance program for state staff discontinued protection for the prescription weight reduction drugs Wegovy and Saxenda resulting from excessive prices.
Along with masking anti-obesity medicine, the Biden administration’s proposed rule goals to crack down on insurers’ use of prior authorizations to disclaim look after Individuals enrolled in personal Medicare plans.
CMS officers mentioned personal Medicare plans overturn 80% of denials when these claims are appealed. Nonetheless, lower than 4% of rejected claims are appealed – a sign enrollees may not contest inappropriate denials.
Meena Seshamani, CMS Deputy Administrator and Director of the Middle for Medicare mentioned this highlights how individuals are denied look after which they qualify.
“What this implies is that extra sufferers might probably have entry to care if inappropriate prior authorization didn’t block it,” she mentioned.
Contributed: Karen Weintraub
