As a weight management medication, Wegovy has gained much attention in the country for its effectiveness in weight loss. With the ever-increasing rate of obesity across the United States, one of the most asked questions pertains to whether Medicaid or Medicare covers this drug and, if so, under what circumstances. This paper considers the current coverage landscape, the eligibility requirements, and what beneficiaries need to know about Wegovy.
Medicare coverage of Wegovy
Traditionally, Medicare has excluded coverage of weight loss drugs, such as Wegovy, thanks to a law that treats those medications as cosmetic, not medically necessary. Recent events, though, have shifted this stance. The Centers for Medicare & Medicaid Services announced that Medicare Part D plans may cover Wegovy if it is prescribed for specific medical conditions-particularly for patients with established cardiovascular disease who are also overweight or obese.
The new coverage policy is based on the recent FDA approval of Wegovy for reducing the risk of major adverse cardiovascular events in adults with obesity or overweight. Thus, such patients will be qualified to receive Medicare Part D. However, individuals looking to Wegovy for weight management in the absence of comorbid health conditions are excluded from this coverage.
As of 2024, under these new guidelines, 3.6 million Medicare beneficiaries will be potentially covered for Wegovy. The list price for the drug is about $1,349 per month, while actual costs will vary on individual plans and out-of-pocket expenses. Any beneficiary should consult specific details related to their Medicare plan as potential costs and nuances regarding coverage may differ.
Wegovy Medicaid coverage
Medicaid’s approach to covering Wegovy is less clear. While Medicaid programs are statutorily required to cover FDA-approved drugs for medically accepted indications, anti obesity medications such as Wegovy are one class in which states have the option to exclude from coverage.
To date, only 13 state Medicaid programs cover GLP-1 medications like Wegovy for the specific indication of obesity. Many of these cover these medications based on prior authorization or require a specific Body Mass Index (BMI). Notably, all states are required to cover these medications for children under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
In the light of the updated policy, states will be obliged to cover Wegovy if it was prescribed for the prevention of cardiovascular diseases in patients with obesity. Such extended requirement is a part of one growing recognition of obesity as a chronic condition that requires medical treatment.
Eligibility requirements
For Wegovy Coverage through Medicare and Medicaid Eligibility, beneficiaries will need to meet the following medical conditions:
- For Medicare: These services are covered for, by and large, patients with established cardiovascular disease who are overweight or obese. Patients not falling within this category are excluded from the coverage.
- For Medicaid: The coverage criteria vary across states but most states consider obesity that poses a threat for cardiovascular events. Prior authorization and threshold BMI may further be determined by the state.
Beneficiaries should consult with healthcare providers about eligibility criteria and broach the subject of potential medical necessity that could justify coverage of Wegovy for indications other than weight loss.
What you need to know
As the world of drug coverage continues to evolve with the Biden administration’s proposed regulations, millions more may find access to weight-loss medications like Wegovy through Medicare and Medicaid. Here are the key points:
- Cost implications: Beneficiaries may incur significant out-of-pocket costs even when coverage is provided, as coinsurance rates lie in the range of 25% to 33% depending on the plan.
- Future changes: In this regard, the Inflation Reduction Act will implement an annual out-of-pocket cap on drug spending starting in 2025, providing additional financial relief for beneficiaries who rely on expensive drugs like Wegovy.
- Consultation is key: It is important that one considering Wegovy, consult with doctors and insurance providers on the eligibility criteria and coverage based on the specific plan one has.
While both Medicaid and Medicare have made steps to start paying for Wegovy in specific medical situations, beneficiaries need to consider further their eligibility and costs involved. Updates, however, will be hugely paramount, given the policy of constant evolution, in regards to beneficiaries who have planned on getting treatment over overweight issues.
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