Friday, March 29, 2024

Anthem is among health insurers now covering anti-obesity drug if it is prescribed to reduce the risk of heart attack and stroke

One of Kentucky's major health insurers is among the first that have "agreed to start paying for the popular anti-obesity drug Wegovy for certain people on Medicare with heart-related conditions," The Wall Street Journal reports. Kentucky has the highest share (about 2.1%) of a state's population that have prescriptions for the new class of weight-loss drugs.

Elevance Health, the corporate parent of Anthem, joined CVS Health and Kaiser Permanente in covering Wegovy to reduce the risk of heart attacks and strokes in beneficiaries "who have cardiovascular disease, meet body-weight criteria and are covered by a Medicare drug-benefit plan," report the Journal's Peter Loftus and Anna Wilde Mathews.

State table shows Medicaid coverage numbers for March. FFS
means "fee for service," which is separate from managed care.
"Elevance, which operates many Blue Cross and Blue Shield health plans, also said it would extend coverage to people insured by a commercial plan" and would make the change in the next few weeks. "A committee of outside advisers to Elevance Health’s CarelonRx unit, which manages pharmacy benefits, has approved the use of Wegovy to reduce the risk of major cardiovascular events. . . . The company also is working with state-government agencies to determine Medicaid coverage of Wegovy." Anthem manages the Medicaid care of about 172,000 Kentuckians; county-level numbers are available.

"The insurers’ moves open up reimbursement of the coveted but costly class of weight-loss drugs, which had previously been excluded from Medicare coverage by a U.S. law and which many private health plans had resisted reimbursing because of the expense," the Journal notes. "The decisions will ease the financial burden on people who had been paying more than $1,000 out of pocket each month because their health plan wouldn’t cover the medicines, and spur use among people who couldn’t afford the heavy cost or didn’t want to pay for it. Other Medicare and commercial health plans might now feel pressure to follow suit and begin coverage. But the widening coverage could result in billions of dollars in additional drug spending by health insurers that have struggled to keep a lid on rising health costs. Wegovy lists for about $1,349 a month."

U.S. Sen. Bernie Sanders (I-Vt.), chair of the Senate's health committee, this week called on insurers to charge Americans no more than they charge in Canada for the drugs. That would lower their prices by about two-thirds.

"The insurers’ decisions arose from new guidance issued last week by the Centers for Medicare and Medicaid Services," the Journal notes. Medicare Part D plans, "which are administered by private insurers, might cover anti-obesity medications if the drugs receive approval for an additional use. Their use for weight-loss alone would still be excluded from coverage. That new guidance applies to Wegovy because the Food and Drug Administration this month approved the weight-loss drug’s use reducing the risk of heart attacks and strokes in people with a history of heart disease, and who have a body-mass index above certain thresholds. A study showed Wegovy reduced cardiovascular risk by about 20% versus a placebo."

Kentucky-based Humana, which manages the care of 155,000 Kentuckians on Medicaid and has a broad paying-customer base in the state, said it is reviewing the CMS guidance. UnitedHealth Group, which covers more than 91,000 Kentucky Medicaid beneficiaries and has many paying customers in the state, declined the Journal's request for comment.

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