Semaglutide: A Diet Drug Dilemma for Medicare with a $145 Billion Price Tag

A significant proportion of Medicare beneficiaries may qualify for the weight loss medication semaglutide, dependent on cardiovascular health criteria.

Costs could range from $10 billion to $145 billion annually, based on how broadly cardiovascular disease is defined, highlighting a critical decision point for Medicare Part D coverage.

A brief research report found that 61% of Medicare-eligible adults have a BMI of 27 or higher, which means they may benefit from a GLP-1 receptor agonist like semaglutide for weight loss. However, the number of patients who will be eligible for semaglutide under new Medicare Part D plan guidelines that require patients to also have established cardiovascular disease will vary depending on how cardiovascular disease (CVD) is defined.

Cardiovascular Disease Criteria and Medication Costs

When established cardiovascular disease is narrowly defined, only 1 in 7 Medicare beneficiaries with elevated BMI would likely be eligible to receive semaglutide, adding a maximum annual costs of $34 billion in additional drug spending. However, if any beneficiary with elevated cardiovascular risk was to become eligible for semaglutide, Medicare could face additional annual costs of up to $145 billion. The findings are published today (August 26) in Annals of Internal Medicine.

Semaglutide is a medication primarily used for the treatment of type 2 diabetes and obesity. It functions as a GLP-1 receptor agonist, which helps to increase insulin secretion and decrease sugar levels in the blood. Notably marketed under brand names such as Ozempic, Rybelsus, and Wegovy, semaglutide has gained prominence for its effectiveness in managing blood sugar levels and promoting significant weight loss.

Research Methodology and Eligibility Expansion

Researchers from Brigham and Women’s Hospital, Harvard Medical School, and Northwestern University examined NHANES (National Health and Nutrition Examination Survey) between 2011 and 2020 to the Medicare beneficiaries who are most likely to be newly eligible for semaglutide based on SELECT trial criteria. They also describe which beneficiaries had any increased risk for future cardiac events and could be eligible pending future evidence generation and Part D coverage decisions.

The researchers then estimated the maximum cost to Medicare Part D that would arise from providing coverage to these various groups of patients by multiplying the number of newly eligible Medicare beneficiaries by the annual net price of semaglutide, generated by subtracting a 41% average discount from the manufacturer list price of the medication in March 2024.

Economic Implications and Policy Considerations

The data showed that approximately 61% of Medicare-eligible adults with complete data had obesity and would potentially benefit from semaglutide for its weight loss benefits. However, when established cardiovascular disease is defined narrowly as in the SELECT trial, only 1 in 7, or 3.6 million people, would be likely to be newly eligible for semaglutide.

Alternatively, if a more liberal definition of established CVD risk were used by Part D plans, then 15.2 million people would be eligible. Even in the most likely scenario where conservative definitions of CVD are used and many people do not stay on semaglutide long-term, Medicare spending could increase by $10 billion annually. The authors note that the analysis estimates maximum budgetary impacts but is not a spending projection and does not account for future payment reforms via the Inflation Reduction Act.

Reference: “Estimating New Eligibility and Maximum Costs of Expanded Medicare Coverage of Semaglutide for Cardiovascular Risk Prevention” 26 August 2024, Annals of Internal Medicine.
DOI: 10.7326/ANNALS-24-00308