
New Proposal Aims to Expand Medicaid and Medicare Coverage for Obesity Drugs
Key Takeaways
- The proposal aims to expand Medicare and Medicaid coverage to include anti-obesity medications, recognizing obesity as a disease.
- Anti-obesity medications have demonstrated safety and efficacy, but current legislation restricts Medicare Part D coverage.
If made official, the proposed rule would give Part D and Medicaid beneficiaries expanded coverage to antiobesity drugs starting in 2026.
The Biden administration has put forth a proposal to
“Increases in the prevalence of obesity in the United States and changes in the prevailing medical consensus towards recognizing obesity as a disease since the beginning of the Part D program in 2006 have compelled CMS to re-evaluate Part D coverage of anti-obesity medications (AOMs) for Medicare Part D enrollees with obesity,” the proposal writes, highlighting circumstances “where the drug’s prescribed use is not for a medically accepted indication (MAI) that is currently covered under Part D.” If made official, pending an endorsement from the Trump administration, their reevaluation would carry important implications for Part D beneficiaries.
AOMs have demonstrated great safety and efficacy throughout numerous randomized controlled trials (RCTs) over the years, as indicated by a 2021 literature review.3 This analysis surveyed 35 RCTs featuring robust data on 5 AOMs FDA-approved for long-term use: liraglutide (Saxenda), orlistat (Xenical, Alli), bupropion-naltrexone (Contrave), phentermine-topiramate (Qsymia), and semaglutide (Wegovy). Liraglutide and semaglutide in particular are members of the glucagon-like peptide 1 (GLP-1) receptor agonist class that has revolutionized obesity management in recent years. Despite their well-documented impact on weight loss and minimal rates of serious adverse events, decades-old legislation has prevented Medicare Part D’s coverage from extending to “weight loss” drugs, no matter that the medications are intended to treat the disease of obesity.1
The new proposal aims to reinterpret this ruling to allow plan coverage of AOMs when their purpose is to address a patient’s obesity and long-term weight management to hopefully prevent associated complications, comorbidities, and conditions. Notably, this reinterpretation would apply to Medicaid plans as well.2
If the Trump administration supports the proposal, CMS anticipates an additional 3.4 million patients who use Medicare—and 4 million who use Medicaid—could qualify for obesity medications.1 Earlier this year, a survey from
The proposal is expected to be published in the Federal Register on December 10.
References
1. Sanger-Katz M. Obesity drugs would be covered by Medicare and Medicaid under Biden proposal. New York Times. November 26, 2024. Accessed November 26, 2024.
2. Medicare and Medicaid Programs: Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly. Federal Register. Accessed November 26, 2024. https://www.federalregister.gov/public-inspection/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare
3. Ahmad NN, Robinson S, Kennedy-Martin T, Poon JL, Kan H. Clinical outcomes associated with anti-obesity medications in real-world practice: a systematic literature review. Obes Rev. 2021;22(11):e13326. doi:10.1111/obr.13326
4. Montero A, Sparks G, Presiado M, Hamel L. KFF Health Tracking Poll May 2024: the public’s use and views of GLP-1 drugs. KFF. May 10, 2024. Accessed November 26, 2024.
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