Wegovy Heart Health Approval does not imply broad insurance coverage | Wilnesh News

In the United States, Wegovy isn’t just for weight loss anymore.

The blockbuster drug was one of a handful of weight-loss drugs that surged in popularity last year and is now approved in the U.S. for heart health.But that may not translate into broader insurance coverage for weekly injectable drugs Novo Nordisk and similar obesity treatments.

Some employers and other health plans remain reluctant to cover Wegovy because of its high cost Price tag of $1,350 per month, which they say could severely squeeze their budgets. They also have other questions, such as how long patients actually receive treatment.

Some insurance industry experts told CNBC that at least some plans will take note of Wegovy’s new approval and begin evaluating whether to cover the treatment the next time their prescriptions are renewed. That could mean difficult decisions for insurance companies, and it could mean a patchwork insurance system for Americans seeking treatment.

“The more benefits weight loss drugs bring, I think the more pressure there will be to start getting these drugs on formularies and bringing them into standard insurance plans,” said John Crable, the company’s senior vice president. Enterprise synergy, a national insurance and employee benefits brokerage and consulting firm. “But my gut tells me it’s going to take more to convince some insurance companies.”

Wegovy is part of a class of drugs called GLP-1, which mimic hormones produced in the gut to suppress a person’s appetite and help regulate blood sugar. Coverage for these treatments for weight loss varies.

About 110 million U.S. adults are obese, and about 50 million of them have insurance coverage for weight-loss drugs, a Novo Nordisk spokesman said in a statement. The company is actively working with private insurers and employers to encourage broader coverage of these drugs and to advocate for Medicare to begin covering them, the spokesperson added.

The Centers for Medicare and Medicaid Services is reviewing the FDA’s expanded approval of Wegovy and will share more information as appropriate, an agency spokesperson said in an email.

State Medicaid programs will be required to cover Wegovy’s new cardiovascular uses, the spokesman added.go through law, Medicaid must cover nearly all FDA-approved drugs, but weight loss treatments are among a small group of drugs that can be excluded from coverage.About one-fifth of state Medicaid programs Currently covered GLP-1 drugs for weight loss.

Some of the largest insurance companies in the United States, such as CVS Health Aetna, covers these treatments.

But many employers don’t think so.October poll The International Foundation for Employee Benefit Plans (IFEBP) surveyed more than 200 companies and found that only 27% provided coverage for GLP-1 weight-loss drugs, while 76% covered these drugs to treat diabetes. Notably, 13% of employers said they were considering underwriting bariatric insurance.

U.S. Food and Drug Administration officially recognized Wegovy will be used for weight management in 2021. Earlier this month, the agency made a landmark decision to expand approval after finding Wegovy reduced the risk of serious cardiovascular complications in adults with obesity and heart disease.

The decision was based on a five-year late-stage trial that showed weekly injections of Wegovy reduced the overall risk of heart attack, stroke and cardiovascular death by 20 percent.

The approval demonstrates that Wegovy and potentially similar drugs have significant downstream health benefits for serious diseases caused by excess weight. Obesity increases the risk of many diseases, such as diabetes, heart disease and even some cancers.

It also challenges what some health experts say is an “outdated” narrative that has given some insurance companies pause: that weight-loss treatments provide only cosmetic, not medical, benefits.

“We have not previously found that any anti-obesity drug reduces the risk of heart attack and stroke,” Dr. Jaime Almandosis a weight management and metabolism expert at UT Southwestern Medical Center in Dallas. “The evidence that we have shows that treating obesity essentially saves lives, and I think that really changes the conversation.”

Some health experts believe that covering Wegovy and other GLP-1 weight loss drugs could lower health care costs for plans and improve future health outcomes for patients.

Sean GremingerThe president and CEO of the National Alliance of Healthcare Buyers Alliance said employers would be “very willing to cover” the cost of these drugs if they can effectively reduce long-term costs.a member of that group Represents private, public, nonprofit and union and Taft-Hartley organizations that spend more than $400 billion annually on health care.

But he said it could be years before employers have concrete data on the potential cost savings of covering these treatments.

Greminger added that employers are “less concerned” about the impact weight-loss drugs will have on overall health care spending 10 years from now. Their focus is on providing care to current employees, some of whom will eventually leave the company.

Employers have other concerns, including long-term data on GLP-1 weight loss and patients stopping the drugs too early. Greminger said some employers also don’t know whether patients must continue using Wegovy for the rest of their lives or whether they can eventually taper their use.

Obesity and heart disease are chronic conditions, which means most patients must continue taking Wegovy along with diet and exercise to maintain health benefits. Novo Nordisk said it was “not unexpected” that its clinical trial data showed that people taking Wegovy regained weight after stopping the drug.

“This supports the belief that obesity is a chronic disease that requires long-term management, and like hypertension or high cholesterol, most patients will remain in treatment long-term in order to continue to experience the benefits of the medication,” Novo said. De said in a statement.

But Greminger said the standard of care for long-term users of weight-loss drugs is “constantly changing.”

He said ditching the weight-loss drug wasn’t a decision the board wanted to make, but it did so because the state’s program was “under financial siege” because of Wegovy. The treatment cost the state health plan nearly $87 million last year, according to one agency. Status introduction Starting in January.Overall, GLP-1 weight loss drugs cost approximately $102 million 2023.

An outside consultant projects that if the state plan continues to pay for these treatments, it will lose $1.5 billion by 2030.North Carolina also estimates that continued coverage of GLP-1 weight loss would double premiums for all 482,000 people positive employees and dependents of the program, even those not taking their medications.

Falwell said the state has been working with Novo Nordisk Eli Lilly and Company, Zepbound, the manufacturer of a similar treatment, reached an agreement on cost. But he noted that the companies rejected the state’s recommendations “every time.”

A spokesman for Eli Lilly said the company is committed to working with health care, government and industry partners “to help those who may benefit from Zepbound get it, but barriers to making that happen remain.” The spokesperson added He said that insurance policies “have not kept up with the pace of science.”

Novo Nordisk said in a statement that it urged Falwell and state health plans to “put patients first” and reconsider the decision to remove coverage for the weight-loss drug.

A Novo Nordisk spokesman said it would be “irresponsible to deny patients coverage for an important and effective FDA-approved obesity treatment” and that the company will continue to work with state health program officials to resolve any potential cost issue.

Both drugmakers have launched programs to help patients, with or without commercial insurance, afford weight loss treatments.

Novo Nordisk said savings plan Wegovy can help uninsured patients save up to $500 every 28 days. The company also said that in the United States, about 80% of Wegovy patients with commercial insurance for the drug pay $25 or less per month.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said increased competition in the weight-loss drug market could force both companies to lower the cost of injectable treatments.The organization represents community-based regional health plans covering more than 18 million Americans nationwide

Health plans may also be more open to covering convenient and potentially cheaper oral medications, which some drugmakers are racing to develop. These cheaper options may be a few years away, though. These include cheaper generic versions of existing GLP-1, as well as treatments from rival drugmakers.

Julie Stich, vice president of content at IFEBP, said more employers may start considering covering Wegovy after it receives greater approval.

But plans that decide to include Wegovy in their next formulary update may consider implementing certain requirements to control costs. These requirements will look different for the two Wegovy-approved uses.

According to an October IFEBP survey, most employers who cover GLP-1 weight loss already use cost controls.

Nearly a third of the companies said they use “step therapy,” which requires their members to try other lower-cost drugs or weight-loss methods before using GLP-1. About 16% of employers use certain eligibility rules, such as requiring employees to have a certain BMI (body mass index) to get coverage.

Other employers apply financial requirements, such as annual or lifetime spending caps on treatment. For example, the Mayo Clinic’s employee health plan added $20,000 to its lifetime coverage limit for prescriptions for weight-loss drugs written after Jan. 1.

Meanwhile, some players in the insurance industry are working to find ways to help health plans manage the cost of treatment.

last week, CignaThe Pharmacy Benefits Administration said it will limit annual increases in GLP-1 spending by employers and other health plans to a maximum of 15%. Currently, some of the company’s clients are seeing spending on these treatments increase by 40% to 50% annually.