Biden Proposes Coverage of Obesity Drugs in Medicare, Medicaid

Medicare and Medicaid recipients with obesity would have access to coverage of pricey GLP-1 receptor agonists like semaglutide (Wegovy) or tirzepatide (Zepbound) under a regulation proposed Tuesday by the Centers for Medicare & Medicaid Services (CMS).

Current law “excludes drugs used for weight loss from Medicare prescription drug coverage,” CMS administrator Chiquita Brooks-LaSure said on a call with reporters. “This exclusion makes these drugs an optional drug benefit for Medicaid programs. Historically, this has meant that drugs used for weight loss, even when used for treatment of individuals with obesity, have been excluded from Medicare prescription drug coverage for Medicaid,” with some states covering them and others not.

However, “the medical consensus has evolved,” she continued. “The medical community today agrees that obesity is a chronic disease … And it’s on the rise across the United States, [where] more than 40% of people have obesity.”

“During my time as CMS administrator, I have heard from countless people about how this coverage exclusion is a barrier preventing people from treating obesity and living healthier lives,” said Brooks-LaSure. “People with obesity deserve to have affordable access to medical treatment and support, including anti-obesity medications for this disease, just as a person with type 2 diabetes can access these medications to get healthy. That’s why we’re proposing to revise our interpretation of the law and provide coverage of anti-obesity medications for the treatment of obesity, and give millions of people [the] opportunity to get the care they need.”

The proposed reinterpretation would “permit coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to reduce excess body weight and maintain weight reduction long-term for individuals with obesity,” according to a CMS fact sheet. This is similar to what the agency did when it came to covering drugs to combat wasting and cachexia in AIDS patients, Meena Seshamani, MD, PhD, director of the Center for Medicare, said on the call.

“That was another situation where the statute had said that [the drugs] could not be used for anorexia and weight gain,” she said. “With AIDS wasting, that also was seen as a medical condition, for which drugs for AIDS wasting could be covered. So it was a similar path to that.”

Coverage of GLP-1 agonists would not, however, be extended to patients who are overweight but without obesity, “as overweight is not considered a disease.” the fact sheet noted. “Therefore, we would continue to exclude anti-obesity medications from Part D coverage when being used in individuals who are overweight but without obesity or another condition that is a medically accepted indication.”

As for the cost of coverage, CMS estimates that Medicare will spend $25 billion over a 10-year period on the GLP-1 drug coverage, Seshamani said. On the Medicaid side, CMS estimates that the cost will be $14.8 billion over 10 years, with the federal government picking up $11 billion and the states paying the remainder, Dan Tsai, director of the Center for Medicaid and CHIP, said on the call.

“States are feeling substantial state budget pressure, and we are doing our part to make sure that patients, Medicaid enrollees all across the country can get access to life-saving and life-altering medications,” he said. “And we would urge drug manufacturers to do their part as well, and make sure they’re thinking about offering fair, appropriate prices to the Medicaid programs all across the country.”

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