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    • Medicare will cover expensive weight-loss drugs under the Biden plan.
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    Medicare will cover expensive weight-loss drugs under the Biden plan.

    Harry Posted on

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    The Biden administration announced plans Tuesday to provide coverage for a range of expensive anti-obesity drugs, including Wegovy and Zepbound, for those enrolled in Medicare and Medicaid.

    Medicare, the federal health program for adults age 65 and over prohibited by law from covering weight-loss medications for older Americans who are obese but do not have diabetes or heart disease.

    The Biden administration estimates that 3.4 million Americans on Medicare will be eligible for drugs with a retail price of more than $1,000 a month starting in 2026, under a rule proposed by the U.S. Department of Health and Human Services. While some states currently cover obesity medications for people enrolled in Medicaid, most do not. The proposed rule would provide coverage for an estimated 4 million Medicaid recipients.

    Centers for Medicare and Medicaid officials estimate that anti-obesity drugs will cost Medicare and Medicaid about $40 billion over a decade. States are expected to pay about $3.8 billion of that total for Medicaid enrollees.

    CMS officials acknowledged that the proposed rule, which requires a lengthy process to collect and review public comments, should be finalized after President-elect Donald Trump takes office next year. Trump nominated Robert F. Kennedy Jr. to lead HHS, and Kennedy has said in media interviews that that’s what Americans want him to do. focus on their diet instead of relying on medication.

    Americans have had a hard time affording a class of blockbuster weight-loss drugs called GLP-1 or glucagon-like peptide-1 receptor agonists. The drugs were first used to treat diabetes, but drugmakers have introduced newer brands approved for people with obesity, such as Wegogy and Zepbound.

    Dr. “This is a tremendously positive step for the White House and CMS to ensure that Medicaid and Medicare enrollees, who often face the disproportionate burden of obesity, receive coverage for anti-obesity medications,” said Fatima Cody Stanford. He’s an obesity medicine specialist at Massachusetts General Hospital and Harvard Medical School in Boston.

    Medicines are expensive. For example, the list price of Novo Nordisk’s weight-loss drug Wegovy is $1,349 per month. By comparison, the drug sells for $186 in Denmark, $140 in Germany and $92 in the United Kingdom. documents It was presented at a Senate Health, Education, Labor and Pensions Committee hearing in September.

    during September hearingSenators grilled Novo Nordisk’s top executive about why the Danish company charges so much more than Americans. wegovy and the diabetes drug Ozempic fares better than patients in Europe.

    Employers and private insurance companies that provide health insurance benefits to workers largely cover diabetes medications like Ozempic.

    Novo Nordisk’s Ozempic and Wegovy are based on the GLP-1 drug semaglutide, but Wegovy is usually given at a higher dose. Zepbound and the diabetes drug Mounjaro are manufactured by Eli Lilly and are based on the drug tirzepatide, which is both a GLP-1 and has a second mode of action that makes them even more effective at weight loss.

    A survey shared last week by benefits consultant Mercer found that 44% of all major employers cover GLP-1 drugs for obesity this year; This rate was 41% last year.

    Biden administration officials did not immediately say how much it would cost taxpayers to expand coverage of weight-loss drugs to millions of Americans. Biden administration officials have said obesity drug coverage would reduce out-of-pocket expenses by up to 95% for Medicare enrollees seeking these prescription drugs.

    Earlier this year, North Carolina’s health insurance program for state employees discontinued coverage For prescription weight loss drugs Wegovy and Saxenda due to high costs.

    In addition to covering anti-obesity drugs, the Biden administration’s proposed rule aims to restrict insurers from using prior authorization to deny care to Americans enrolled in private Medicare plans.

    Private Medicare plans turn down 80% of those denied when those claims are challenged, CMS officials said. However, less than 4% of rejected claims are appealed; This is an indication that enrollees cannot appeal improper rejections.

    CMS Deputy Administrator and Center for Medicare Director Meena Seshamani said this shows how people are being denied the care they deserve.

    “What this means is that more patients would likely be able to access care if they were not hindered by improper prior authorization,” he said.

    Contributed by Karen Weintraub

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