Why doesn’t Medicare cover drugs like Ozempic for weight loss?

Medicare Half D, which gives prescription drug protection, will now cowl the weight-loss medicine Wegovy in instances the place the affected person is susceptible to a coronary heart assault or a stroke. 

Wegovy belongs to a gaggle of medication referred to as GLP-1s — which embrace Ozempic and Mounjaro — that had been developed for these with kind 2 diabetes to handle their blood sugar, and have now grow to be a preferred selection of drug to assist with weight reduction. The U.S. Meals and Drug Administration has not accepted Ozempic and Mounjaro for weight reduction, though it has accepted Wegovy and a model of Mounjaro known as Zepbound.

Medicare beneficiaries have entry to medication like Ozempic in the event that they’re getting used to deal with diabetes. However Medicare Half D doesn’t present protection for GLP-1s for those who’re simply making an attempt to drop some weight, mentioned John Cawley, a professor of economics and public coverage at Cornell College. He famous this implies a excessive share of Medicare recipients who’ve weight problems received’t have the ability to get entry to those weight reduction medication. 

Whereas Cawley says these medication might present well being advantages for these sufferers, there’s a legislation, known as the Medicare Modernization Act of 2003, that prohibits protection of weight-loss medication.

This ban is a stronger model of 1990 Medicaid guidelines, which gave states the choice to ban protection of weight-loss medication, fertility medication and beauty medication. Some weight-loss medication previously, not GLP-1s, had been ineffective or “downright harmful,” which is why states had been allowed to exclude them, Cawley famous.  

Cawley mentioned that lawmakers have launched the Deal with and Cut back Weight problems Act, a legislation that might permit Medicare Half D to cowl medication like GLP-1s to deal with weight problems. Nonetheless, it has did not be enacted.

“A part of it’s value,” Cawley mentioned. “The listing costs are over $1,000 a month.” 

James Bailey, an affiliate professor of economics at Windfall Faculty, mentioned Medicare receives rebates that deliver down the value, however the medication are nonetheless very costly. 

The Kaiser Household Basis discovered that in 2022, Medicare spent $5.7 billion on Ozempic and different medication used to deal with diabetes — a drastic improve from $57 million in 2018. 

Jeah Jung, a professor of well being administration and coverage at George Mason College, mentioned Half D’s protection of Wegovy might improve the Medicare Half D prices, in flip rising premiums. 

However it’s unclear how a lot it’ll impression Half D and once we’ll see these results, Jung mentioned. 

Jung identified that decreasing the chance of heart problems might save medical prices sooner or later. 

Cawley mentioned the Congressional Funds Workplace checked out the price of offering Medicare protection of anti-obesity drugs to sufferers, and located that the price of GLP-1s would fail to be absolutely offset by different well being care financial savings.

However Cawley mentioned it nonetheless might probably be an amazing profit for society. “Not every part saves cash that’s worthwhile,” he mentioned. Cawley mentioned he stays cautious about GLP-1s as a result of there could also be unintended effects we don’t learn about, however he famous they’ve been prescribed since 2005 and have proven to scale back cardiovascular danger. 

Demand for these medication is so excessive that Costco is now offering Ozempic prescriptions with its well being care associate, Sesame, for a $179 three-month plan that features a video session, a GLP-1 prescription if wanted and entry to a well being care supplier, reported CNN. However the price of the weight-loss medication usually are not included within the $179, and Cawley questions whether or not that is one of the best ways of acquiring the drug as a result of chances are you’ll wish to go for an in-person check-up so you’ll find out in case you have any obesity-related medical circumstances. 

Sen. Bernie Sanders of Vermont has criticized the excessive value of Ozempic, declaring in a press launch that it prices at most $5 a month to fabricate the drug. That’s based mostly on a research from Yale College, King’s Faculty Hospital in London and Medical doctors With out Borders. 

Cawley mentioned the weight-loss drug house is changing into extra aggressive, which implies costs might drop. For instance, he mentioned the pharmaceutical firm Eli Lilly and Firm not too long ago launched the weight-loss drug Zepbound.

Underneath the 2022 Inflation Discount Act, the federal government is now capable of instantly negotiate drug costs with drugmakers. Late final 12 months, the Biden administration launched the primary 10 medication topic to negotiation. Ozempic could possibly be subsequent.