By Patrick Wingrove
NEW YORK (Reuters) - Older Americans are having little success getting prescriptions for 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, according to their doctors.
In interviews with Reuters, seven obesity and heart disease specialists from various parts of the United States said their prescriptions for the Novo Nordisk (NYSE:NVO) drug have been denied repeatedly by the healthcare companies that administer Medicare drug benefits, with some prescriptions approved only following an appeal for each application.
One doctor said that none of the 10 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.
"If there's a medication that can help reduce your risk further and help control your symptoms and reduce hospitalization, to have insurance say that it's not going to be covered is problematic," said one of the physicians, Dr. Noor Khan, a specialist in obesity and bariatric medicine at the University of Pittsburgh Medical Center.
"I have not been able to determine the pattern of who is getting covered and who is not - even when we have evidence of MI (myocardial infarction, meaning heart attack) or stroke," added Dr. Holly Lofton of New York University Langone, a general practitioner specializing in obesity.
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 so-called 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 the billions of dollars.
Novo and rival Eli Lilly (NYSE:LLY) are seeking to widen insurance coverage for their weight-loss drugs, investing in large clinical trials intended to show specific health benefits in addition to helping people shed pounds.
The U.S. Food and Drug Administration in March approved a new use of Wegovy for heart disease, based on clinical trials showing a 20% reduction in heart attack, stroke or other cardiovascular-related death.
The Centers for Medicare & Medicaid Services, the U.S. agency that administers the program, the same month issued guidance to health insurers to cover the drug for that use. The agency did not immediately respond to a request for comment.
A Novo Nordisk spokesperson said the company will continue to work with payers and policymakers to ensure that seniors living with obesity have insurance coverage.
Two companies that manage prescription drug benefits for Medicare patients, CVS Health (NYSE:CVS)'s Caremark and UnitedHealth Group (NYSE:UNH)'s Optum RX, said it is possible for patients to access Wegovy for the cardiovascular indication, but declined to say how many plans were covering the drug or how many would in the future. Others did not respond to requests for comment.
'VARIATION IN 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."
Consultant Jeff Levin-Scherz at Willis Towers Watson (NASDAQ:WTW), a company that advises businesses on healthcare benefits, said covering Wegovy this year would hurt Medicare plans margins, as they would not have been able to adjust for the change in costs.
They may need to widen coverage even further. Lilly's 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.
Novo and Lilly have also lobbied U.S. lawmakers to pass a law allowing Medicare to cover their drugs just for obesity.
Morningstar analyst Karen Andersen said the lack of uptake for Wegovy among Medicare plans does not seem to be affecting Novo's sales. Soaring demand among younger Americans whose health insurance is covered by their employer continues to outpace supply.
Meanwhile, doctors with Medicare patients have the task of preparing them for having their coverage rejected.
"I spend about 20 to 30 minutes creating realistic expectations because (Medicare) has a very tight window of what they're going to agree to pay for or not," said Dr. Kyla Lara-Breitinger, a cardiologist at the Mayo Clinic in Rochester, Minnesota.