In November 2024, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Program; 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 proposed rule. The Medicare Part D provisions of the proposed rule includes language “to reinterpret the statutory exclusion of agents when used for weight loss such that it would not apply to drugs when used to treat beneficiaries with obesity.” The proposed reinterpretation would also apply to the Medicaid program.
The proposed reinterpretation of Medicare coverage for anti-obesity medications (AOMs) is a critical inflection point in how the federal government approaches the treatment of obesity. While Medicare Part D enrollees currently have access to some GLP-1 receptor agonists for indications other than obesity, the proposed reinterpretation to include Part D enrollees for the treatment of obesity could significantly improve access to these medications and health outcomes for enrollees. These medications, which have demonstrated remarkable effectiveness in weight management, have now transformed the therapeutic landscape. As Medicare considers broadening access to these medications, policymakers face a number of considerations. The expansion could substantially improve health outcomes for millions of Medicare beneficiaries with obesity. At the same time, there are concerns about the cost associated with expanding coverage for additional conditions. Understanding cost dynamics is important as policymakers seek to improve patient access to innovative therapies with responsible stewardship of public resources.
This brief examines the potential impact of Medicare’s proposed reinterpretation, analyzing both the benefits for beneficiaries and the broader economic implications for the Medicare program and its enrollees. We first provide an overview of AOMs, including specific drugs and indications that they have been approved by the FDA to treat. Next, we compare existing estimates of the impact of expanding access Medicare Part D to include these treatments for obesity. We continue by examining the growth in utilization of these drugs since their launch in the U.S. overall and among Medicare and Medicaid populations, we compare prices and spending for these medications in the U.S. and comparator countries. Finally, we look at out-of-pocket costs for certain medications in the Medicare population.
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