New eligibility for semaglutide would cost Medicare billions in spending

Key takeaways:

• Overall, 3.6 million Medicare beneficiaries would be eligible for semaglutide if established CVD is narrowly defined.
• Over 15 million would be newly eligible if Medicare used liberal definitions for established CVD.

High BMI eligibility for semaglutide could cost Medicare up to $145 billion annually, a brief report published in the Annals of Internal Medicine revealed.

According to Alexander Chaitoff, MD, MPH, a research fellow at Brigham and Women’s Hospital, and colleagues, Medicare announced it would allow Part D plans to cover Wegovy (semaglutide, Novo Nordisk) for patients with a BMI of 27 kg/m² or higher and established CVD, regardless of diabetes status.

This came after the SELECT trial showed that semaglutide reduces cardiovascular events in certain patients without diabetes.

“We were excited when we read Medicare's announcement that they would expand coverage, but we still wondered who exactly was going to have access to this drug,” Chaitoff told Healio. “This was especially true because the press release about expanded coverage mentioned individuals with elevated BMI and ‘established CVD,’ which felt somewhat nebulous.”

The researchers assessed 2011 to 2020 National Health and Nutrition Examination Survey data on respondents aged 65 years or older and enrolled in Medicare.

They used four potential definitions of established CVD that Part D could consider:

• self-reported, physician-provided diagnosis of stroke, myocardial infarction, or angina or coronary artery disease (criteria similar to the SELECT trial’s);
• a 10-year atherosclerotic CVD, or ASCVD, risk of 7.5% or more and less than 20%;
• a 10-year ASCVD risk of 20%; or
• fulfillment of any of the three previous criteria.

Overall, 5,111 respondents, or around 61% of Medicare-eligible adults with complete data, had a BMI of 27 kg/m² or more.

Only 3.6 million — or one in seven — people would be highly likely to be newly eligible for semaglutide if Medicare defines established CVD as narrowly as in the SELECT trial, a surprising result to Chaitoff and colleagues.

“While it is good that those with the highest risk of cardiovascular events are going to have the choice to use semaglutide, we show that many patients who might benefit from GLP-1s will unfortunately still not be covered,” he explained. “We know these GLP-1 drugs offer numerous benefits to patients aside from weight loss.”

When the researchers used “more liberal” definitions of established CVD, the amount of people newly eligible increased to 15.2 million (60.9%).

Ultimately, maximum Medicare spending could be between an additional $34 billion to $145 billion a year if all newly eligible beneficiaries received semaglutide.

Chaitoff and colleagues wrote that semaglutide could still result in $10 billion in spending annually, even if Part D plans narrowly define CVD and users do not stay on semaglutide long term.

The main takeaway for primary care providers “is not to confuse the many media stories about expanded coverage with the idea that now all Medicare beneficiaries will qualify for GLP-1 coverage,” Chaitoff said.

“Even those with very high cardiovascular risk — greater than 20% chance of a heart attack or stroke in the next 10 years — may not qualify,” he told Healio. “This is also to say nothing of other ways access can be limited — ranging from patient out-of-pocket costs, formulary placement, drug shortages and utilization management strategies.”

He added that for right now, “we'll have to try to get patients what they need [while] recognizing that this is a rapidly evolving landscape and who is eligible will likely change in the coming years.”