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The FDA has recently approved a new use for Wegovy (semaglutide), a popular anti-obesity medication. It can now be used to reduce the risk of #heart attacks and #strokes in people with #cardiovasculardisease , who are also overweight or #obesity . This FDA approval marks a significant milestone because it may allow Medicare to cover Wegovy, which was previously not allowed for just obesity treatment. Wegovy belongs to the GLP-1 agonists category, originally designed to treat type 2 #diabetes , but it has also proven effective for weight loss. To avoid confusion, it's important to note that Ozempic, which also contains semaglutide, is prescribed specifically for diabetes and is currently included on many Part D Plan formularies. The FDA's decision opens the door for Medicare to cover Wegovy. (CMS) issued a directive allowing Medicare Part D plans to include Wegovy in their formularies. Since Wegovy is self-administered, its coverage will be provided under #medicare Part C plans(that included prescription drug coverage) and stand-alone Part D drug benefit. If you're looking to use Wegovy for weight loss alone, you won't be eligible. However, if you have cardiovascular disease along with obesity or being overweight, you could benefit from this decision. This approval specifically targets individuals with established cardiovascular disease. 3.6 million beneficiaries represent over a quarter of the 13.7 million Medicare beneficiaries diagnosed with obesity or overweight in 2020, potentially providing access to Wegovy for 1 in 4 individuals. Prior Authorization on All Part C and Part D plans will be required and may require multiple steps, and approval is not guaranteed. Another aspect of prior authorization is step therapy, where you might be required to try lower-cost medications first to see if they work, which could save both you and the plan money. Additionally, 2024 Part C and D plans established their rates without accounting for these added costs, meaning they do not have the funds available to pay for Wegovy. Since they cannot increase premiums during the year, finding the necessary funds is also not a realistic possibility. Estimated Impact on Premiums and Out-of-Pocket Costs If Medicare Part D plans adopt Wegovy and prescribe it to eligible individuals, the cost to the program could range from $268 billion to as much as $1 trillion, depending on various estimates. This significant expense will impact future premiums and out-of-pocket costs for beneficiaries. Alena Marchant www.mpgroup.org [email protected] #medicare #fda #weightloss #insurance #knowmorefacts #knowmorestressless #saddleuphealthplans #mpgroups