Medicare prescriptions for Wegovy jumped after approval for heart disease

Medicare prescriptions for Wegovy jumped after approval for heart disease

Medicare prescriptions for Wegovy, an anti-obesity medication, have increased significantly after the program started covering the drug to prevent heart problems. According to new research from the USC Schaeffer Center for Health Policy & Economics, this surge in prescriptions is a result of Medicare's clarification that health plans administering the Part D benefit could cover Wegovy to reduce the risk of heart complications in beneficiaries with obesity and heart disease.

The FDA's expanded approval of Wegovy for this purpose in 2024 removed the medication from Medicare's statutory exclusion on weight-loss drugs, allowing Medicare Part D plans to cover it for cardiovascular risk reduction in patients with established heart disease who are overweight or obese. However, coverage is not automatic, and the rules are more complicated than many headlines suggest.

Medicare is still prohibited by law from covering Wegovy when used solely for obesity, even if a patient meets BMI criteria. This means that the diagnosis code and medical documentation must clearly reflect cardiovascular disease, not weight management, as the treatment purpose. Seniors should expect their prescribers to justify the medication based on the new FDA-approved indication.

Individual Part D plans still control their formularies, and plans may choose to include Wegovy, restrict it with prior authorization, or place it on a higher cost-sharing tier. Because Wegovy is expensive, many plans are expected to require documentation proving cardiovascular disease and medical necessity. Some plans may also require patients to try alternative therapies first, depending on their internal policies.

Even with coverage, Wegovy will not be cheap for most Medicare beneficiaries. Part D plans can apply deductibles, coinsurance, and specialty-tier pricing to high-cost medications like GLP-1s. Many seniors will face percentage-based cost-sharing rather than flat copays, and costs may shift throughout the year as patients move through the deductible, initial coverage phase, and catastrophic coverage phase.

The FDA's expanded indication applies specifically to people who are overweight or obese and have established cardiovascular disease, including patients with a history of heart attack, stroke, or other qualifying conditions. Medicare coverage follows this same rule: no documented heart disease means no coverage. This distinction is critical because many patients who want Wegovy for weight loss alone will still be denied under federal law.

Despite the headlines, Medicare has not changed its long-standing prohibition on covering weight-loss medications. The only reason Wegovy can now be covered is that the FDA granted a new medical indication unrelated to weight loss. This means Medicare still cannot cover Wegovy, or any GLP-1, when prescribed solely for obesity.

A new pilot program, known as Medicare GLP-1 Bridge, launched this month, aims to broadly expand access to GLP-1s for weight loss through a temporary program. The pilot, largely funded by the federal government, is set to expire after 2027, and health insurers have balked at a longer-term program that would shift costs onto them. However, Medicare will continue to allow coverage of weight-loss drugs for other FDA-approved indications beyond obesity.

Researchers continue to study GLP-1s, which were first approved for Type 2 diabetes, for a range of other conditions. Wegovy has also been approved for the serious liver disease MASH, while other GLP-1s have been approved for conditions including obstructive sleep apnea and chronic kidney disease. As the clinical indications for these medications continue to expand, ensuring that patients can access and afford them remains a challenge.

According to Dr. David Liporace, a board-certified internist, the new coverage could make a significant difference among Medicare beneficiaries. "If we can get that population healthier from the perspective that they are more lean and more active, then they will have less heart disease, they will have less kidney disease, they will have less dementia, which is huge, and they will fall less," Liporace said.

However, not all studies are pointing to overall reduced medical costs. The Congressional Budget Office (CBO) in 2024 put out an analysis that found extending the coverage of GLP-1s to Medicare beneficiaries classified as "overweight" would cost the federal government $35 billion from 2026 to 2034.

Eligible patients must have Medicare Part D coverage, be at least 18 years of age, and meet a certain body mass index (BMI) or higher. If the BMI is lower than 35, patients must also have an attendant medical condition to qualify for the new benefit. After the $50-a-month GLP-1 program ends in 2027, Congress would have to change the federal law that prohibits Medicare from covering drugs for weight loss alone.

As the situation continues to develop, Medicare beneficiaries can visit Medicare.gov or call 1-800-MEDICARE to have a representative pull up their exact plan information. With the new benefit in place, seniors who qualify under the cardiovascular indication may finally gain access to a medication that reduces their risk of heart attack and stroke. However, coverage is not guaranteed, and out-of-pocket costs may still be high depending on the Part D plan.