Despite the FDA's approval of Wegovy (semaglutide) for reducing the risk of cardiovascular events in patients with obesity, physicians are reporting difficulties in getting prescriptions covered by Medicare. The Centers for Medicare & Medicaid Services (CMS) issued guidance to health insurers in March 2023 to cover the drug for this indication, following the FDA's approval based on clinical trials demonstrating a 20% reduction in heart attack, stroke, or other cardiovascular-related death.

Several physicians interviewed by Reuters reported varying success rates in getting semaglutide prescriptions covered by Medicare, ranging from 0% to 50% for patients with a history of heart attack or stroke. The denials persist even after appeals are submitted for each application.

Semaglutide, a weekly injection with a list price of more than $1,300 per month, is part of a growing class of weight-loss drugs being investigated for their potential cardiovascular benefits. Novo Nordisk and Eli Lilly are investing in large clinical trials to demonstrate specific health benefits beyond weight loss, with the goal of expanding insurance coverage for their drugs.

Currently, only 1% of Medicare plans offered by prescription drug benefit managers cover semaglutide for the cardiovascular indication, according to a July 2023 analysis by KFF. While coverage is expected to increase in the coming year, variations in coverage are likely to persist due to the high cost of the medication.

As physicians navigate the challenges of prescribing semaglutide for their Medicare patients with obesity and cardiovascular risk, they must also manage patient expectations regarding coverage and access to this innovative but expensive therapy. Further research is needed to optimize the use of semaglutide and other weight-loss drugs in clinical practice and to assess their impact on patient outcomes and healthcare resource utilization.