Source: Finance Association
① Last month, the US FDA approved simeglutide to reduce the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and obesity or overweight; ② According to calculations, even if only 10% of eligible people (estimated 360,000 people) use the drug for a full year, the D portion of Medicare would require an additional $2.8 billion.
According to the latest analysis report released by the US Kaiser Family Foundation (KFF) on Wednesday (April 24), more than 3 million health insurance beneficiaries may be eligible to receive insurance coverage for this drug since Wegovy is approved for the treatment of heart disease in the US.
Last month, the US Food and Drug Administration (FDA) approved simeglutide (trade name: Wegovy), known as the “magic drug for weight loss,” to reduce the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and obesity or overweight.
KFF said the FDA's decision marks a turning point in GLP-1 drug coverage, as Wegovy is no longer just a treatment for diabetes and obesity.
However, KFF added that some health insurance beneficiaries may still need to pay out of pocket, and some health insurance prescription drug plans may not cover Wegovy until 2025. As more plans cover Wegovy's expenses, Medicare insurance (federal Medicare) budgets are likely to get tight.
According to the report, some Medicare insurance plans Part D (Prescription Drug Plan, Part D) have announced that they will start covering Wegovy within this year, but due to Wegovy's relatively high price and large pool of potential patients, some are unwilling to expand coverage.
KFF said that according to 2020 data, it is estimated that 7% of health insurance beneficiaries (i.e. 3.6 million people) were diagnosed as obese or overweight in 2020 and had cardiovascular disease at the same time, and are covered by Wegovy health insurance.
Based on Wegovy's monthly list price of $1,300 and a 50% reimbursement rate, even if only 10% of eligible people (estimated 360,000 people) used the drug for a full year, the D portion of Medicare would need to spend an additional $2.8 billion.
KFF's analysis also found that health insurance beneficiaries may have to pay out of pocket expenses of 325 to 430 US dollars per month this year, which is unaffordable for many people with lower incomes. Even if this figure falls in the next few years, it is still a heavy burden.
The report also mentioned that if GLP-1 drugs are approved for other uses in the future, it may open up more health insurance coverage channels. For example, Eli Lilly last week announced positive results from its phase III SURMOUNT-OSA clinical trial for treating moderate to severe obstructive sleep apnea (OSA) with obesity.
Eli Lilly is planning to seek FDA approval for this use, which is expected to be the first treatment for sleep apnea on the US market.
edit/lambor