Doctors Struggle to Secure Medicare Coverage for Heart Patients on Novo Nordisk's Wegovy

Older Americans are having little success getting prescriptions for Novo Nordisk A/S’s NVO weight-loss drug Wegovy, covered by Medicare, despite the federal healthcare program’s decision to pay for patients with obesity at risk of heart disease.

In interviews with Reuters, seven obesity and heart disease specialists from various parts of the United States said their prescriptions for Novo Nordisk’s drug have been repeatedly denied by the healthcare companies that administer Medicare drug benefits. Some prescriptions were approved only after an appeal for each application.

Also Read: Don’t Promote Copycat Weight-Loss Drugs Amid Improved Supply, Eli Lilly Asks Doctors, FDA Evaluates.

One doctor said that none of the ten or more appeals she sends each month are granted. Two other physicians said their success rate with appeals was between 10% and 50% for patients with a history of heart attack or stroke.

Medicare, which provides medical coverage for Americans age 65 and older, is prohibited by law from paying for weight-loss drugs or other types of lifestyle medicines.

Wegovy, a weekly injection, carries a list price of more than $1,300 per month, prompting calls from President Joe Biden’s administration and some lawmakers for Novo to lower its price.

With nearly 70% of U.S. adults considered obese or overweight, the cost of covering it for even a fraction of those patients would run into billions of dollars.

Citing a Novo Nordisk spokesperson, Reuters noted that the company will continue working with payers and policymakers to ensure that seniors with obesity have insurance coverage.

A July analysis by KFF, a non-profit that conducts health policy research, showed that only 1% of plans for Medicare patients offered by these middlemen covered Wegovy for heart disease.

Juliette Cubanski, deputy director of KFF’s program on Medicare policy, said plan sponsors often wait until the start of the calendar year to begin coverage of a newly approved prescription drug. Cubanski said she expects more Medicare plans to start covering Wegovy next year, although even then “we’ll see variation in coverage for this drug, just as we do for other expensive medications.”

They may need to widen coverage even further. Eli Lilly And Co’s LLY clinical trials have shown its obesity drug Zepbound can help treat obstructive sleep apnea. Lilly is seeking FDA approval for that use and expects the drug would then be covered by Medicare.

Price Action: NVO stock is down 1.66% at $135.29 at the last check on Friday.

Photo by Tobias Arhelger via Shutterstock