A recent study has revealed that around 3.6 million individuals enrolled in Medicare may soon qualify for semaglutide. Additionally, the study explores various definitions of cardiovascular risk and the potential maximum costs associated with them. If Medicare Part D adopts a strict definition of cardiovascular disease, most patients will still be ineligible, even as new federal expenses could surpass $10 billion.
If Medicare Part D narrowly defines cardiovascular disease, the majority of patients would remain ineligible while new federal spending could still exceed $10 billion.
Currently, federal regulations prevent Medicare from covering medications prescribed exclusively for weight loss. However, in March 2024, Medicare announced that it would begin providing coverage for semaglutide (Wegovy), a well-known glucagon-like peptide-1 receptor agonist (GLP-1RA), for patients with high body mass index (BMI) who also have a diagnosed cardiovascular disease (CVD). This implies that the definition of “established CVD,” which has yet to be officially defined, could significantly influence both public health and Medicare expenses. Researchers at Brigham and Women’s Hospital, which is part of the Mass General Brigham healthcare system, conducted this study and estimated that 3.6 million Medicare recipients are likely to qualify for semaglutide. The study further examines eligibility and possible maximum costs under varying definitions of cardiovascular risk. The findings have been published in Annals of Internal Medicine.
The research team evaluated data from Medicare recipients aged over 65 or those participating in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2020. They discovered that if all patients exhibiting elevated BMI and a history of heart attack, stroke, coronary artery disease, or angina received semaglutide, annual costs to Medicare could reach as high as $34.3 billion after discounts.
According to lead author Alexander Chaitoff, MD, MPH, from the Center for Healthcare Delivery Sciences in the Division of Pharmacoepidemiology at BWH, “When established cardiovascular disease is narrowly defined, only 1 in 7 Medicare beneficiaries with elevated BMI are likely to be eligible to receive semaglutide, but costs to Medicare could still exceed $10 billion per year. In this conservative coverage scenario, this indicates that most beneficiaries with elevated BMI and cardiovascular risk would continue to be ineligible for semaglutide, yet the medication could still emerge as one of the most expensive drugs for Medicare.”
