Opening Medicare to Semaglutide for Obesity and Heart Disease

This is a striking change. Until now, the steadfast refusal of CMS to allow coverage of any obesity medicine by Medicare has been unwavering. Then two weeks ago, FDA granted a new indication for semaglutide for persons with both heart disease and obesity to prevent heart attacks, strokes, and deaths. Now CMS says it’s A-OK for Medicare to cover semaglutide for people with both obesity and heart disease. The agency emailed a statement on Thursday to reporters saying:

“CMS has issued guidance to Medicare Part D plans stating that anti-obesity medications (AOMs) that receive FDA approval for an additional medically accepted indication can be considered a Part D drug for that specific use.”

For those with obesity and no heart disease yet? Check back with us later, after problems with your heart show up. Don’t even try to think about an ounce of prevention versus a pound of cure in this scenario. It makes our heads hurt. Leaving no doubt about this, a CMS spokesperson told Reuters:

“A drug that receives FDA approval for chronic weight management alone would not be considered a Part D drug. If this same drug also receives FDA approval to treat diabetes or reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight, then it would be considered a Part D drug for those specific uses only.”

Welcome News

For sure, this is welcome news. Caroline Apovian, one of the nation’s leading obesity medicine physicians told us:

“I am over the moon with joy for my patients on Medicare who have heart disease. For patients with obesity and heart disease who lost weight on semaglutide and then at 65 switched to Medicare and regained weight due to loss of coverage, this brings a huge sigh of relief.

“This is good news as well for those not yet on Medicare, but living with obesity and heart disease.”

Yes…But

Of course, there’s a catch. Once again, health policy favors waiting for people to develop the complications of obesity before treating this chronic disease that lies at the root of heart disease and so many other chronic diseases. We also note that this news merely cracks the door open to the possibility that a drug plan will cover semaglutide in a narrow set of circumstances. It’s no guarantee and drug benefit plans have countless tricks to frustrate patients who need coverage for any specific medicine.

Obesity Action Coalition CEO Joe Nadglowski offers a broader perspective:

“This is just one battle in a long campaign to obtain better access to obesity care for people living with obesity who rely on Medicare.

“Some percentage of people on Medicare will eventually gain coverage because of this news. It will take time for various drug plans to update their policies. But what about the rest of folks relying on Medicare? Does it make sense to deny obesity care to persons who don’t yet have diabetes or heart disease?

“This ruling makes it clear that we urgently need the more fundamental policy change that the Treat and Reduce Obesity Act will provide.”

Broken Policies for Obesity Care

Health policy denying access to care for obesity explains a lot about why the prevalence and severity of obesity keeps growing. Health systems have a bias that pushes people into ineffective DIY obesity care. Eat less and move more. Come back and see us when you get much sicker, says Medicare.

Yes, a little more coverage for obesity medicines in Medicare is an increment of good news. But it’s only a patch, not a real repair to broken policies for obesity care.

Click here, here, here, and here for more reporting on shift in policy at CMS.

We Are Opening the Gates, painting by Nicholas Roerich / WikiArt

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March 22, 2024