Who benefits from Medicare coverage of semaglutide for cardiovascular risk?
The evolving criteria for coverage mean physicians will need to stay informed and help patients navigate their options during Medicare Open Enrollment
Medicare coverage of semaglutide: ©Zimmytws - stock.adobe.com
Older obese Americans may soon gain Medicare coverage for the weight-loss medication semaglutide, potentially reducing their high risk of heart disease. However, the criteria for eligibility, the number of people who will qualify, and the financial impact on Medicare remain under debate.
A study published in the Annals of Internal Medicine, led by Alexander Chaitoff, M.D., of the VA Ann Arbor Healthcare System and University of Michigan, examined how semaglutide coverage could affect the health care system. Depending on how Medicare and its affiliated insurance plans define eligibility, the number of beneficiaries and the cost could vary widely, impacting millions of people and billions of dollars.
The study estimates that as many as 3.6 million older adults with obesity could qualify for semaglutide coverage if Medicare limits eligibility to individuals with obesity who have already experienced a heart attack, stroke, or have been diagnosed with coronary artery disease or angina. This estimate excludes the approximately 7 million people with both obesity and diabetes, who may already be eligible for semaglutide through its diabetes indication.
The study suggests that if Medicare expands coverage to those with the highest cardiovascular risk scores—without requiring a prior cardiovascular event—an additional 5.1 million Americans could qualify. If the criteria are further broadened to include people with intermediate cardiovascular risk, another 6.5 million could become eligible.
Currently, Medicare has announced it will cover semaglutide for enrollees in prescription drug plans if they have "established cardiovascular disease." However, the lack of a specific definition for this term leaves much ambiguity.
Chaitoff noted that Medicare Advantage and Part D plans could impose additional requirements, such as partial cost-sharing or stricter eligibility criteria. Alternatively, they may follow the model used by the Veterans Health Administration, which provides semaglutide to veterans with obesity and at least one related condition, provided they participate in a long-term weight management program.
"If those plans focus on coverage for people with the same conditions as in the clinical trial, one in seven Medicare participants with obesity would now have access, which is an important expansion,” Chaitoff said in a statement. “However, the other six of the seven would not, and most of them also have an elevated cardiovascular risk.”
According to the study, the cost implications of expanding semaglutide coverage are significant. Based on current pricing, if Medicare allows only those with a history of heart attack or stroke to receive the drug, and if 30% of them start and remain on treatment for a year, Medicare could face costs exceeding $10 billion. The ultimate price Medicare pays will depend on ongoing negotiations between CMS and the drug’s manufacturer.
For physicians, expanding access to semaglutide could help more patients achieve meaningful weight loss, reducing their cardiovascular risk and improving overall health outcomes. However, the evolving criteria for coverage mean physicians will need to stay informed and help patients navigate their options during Medicare Open Enrollment.
"Ultimately, we need to ask ourselves what level of evidence we are requiring for coverage of certain drugs, compared with the level of evidence that we require for other treatments," said Chaitoff. "With all that we know about obesity’s impact on cardiovascular risk, it may be best to accept that a sustained reduction in weight is reasonable enough evidence for coverage."
