CMS Proposal Would Expand Medicare, Medicaid Coverage for GLP-1 Drugs

In the waning days of the Biden-Harris administration, the US Centers for Medicare & Medicaid Services (CMS) has proposed changes that would allow the glucagon-like peptide-1 (GLP-1) receptor agonists to be covered by Medicare for the treatment of obesity.

Current rules prohibit Medicare from providing coverage for GLP-1 receptor agonists—such as semaglutide (Wegovy; Novo Nordisk), liraglutide (Saxenda; Novo Nordisk), and tirzepatide (Zepbound; Eli Lilly), which is a dual glucose-dependent insulinotropic polypeptide (GIP) receptor and GLP-1 receptor agonist—when used solely for weight management and not for another approved indication, like cardiovascular disease or type 2 diabetes. States are allowed—but not required—to provide coverage for weight loss under Medicaid.

As such, the price tag for these agents, which can exceed $1,000 per month, prevents many people from getting them.

“In recognition of the prevailing medical consensus that obesity is a disease, CMS is proposing to reinterpret the statute to no longer exclude antiobesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity,” CMS stated in its Tuesday announcement. “This proposal would provide more Americans access to these transformative medications, improving the health and quality of life for millions of people who have obesity.”

The changes, which would be implemented for contract year 2026, would apply to the Medicare Advantage and Medicare Part D prescription drug programs.

Responding to the news, Richard Kovacs, MD (Indiana University School of Medicine, Indianapolis), chief medical officer of the American College of Cardiology, told TCTMD, “I would applaud making these drugs more widely available to the patients that need them.”

He said the cardiovascular medicine field is still learning what impact greater access to these medications might have. The SUMMIT trial of tirzepatide, presented recently at the American Heart Association 2024 Scientific Sessions, showed these types of drugs might have benefits in patients with heart failure with preserved ejection fraction (HFpEF), he noted. The earlier STEP-HFpEF trial showed some similar HFpEF benefits with semaglutide.

“Every day, cardiologists are seeing patients who have metabolic abnormalities, are obese, are type 2 diabetics, and then mixed into that are all their cardiovascular abnormalities, their atrial fibrillation, their heart failure with preserved ejection fraction, their ischemic heart disease,” Kovacs said. “And so having better coverage and more options for these patients I think is important.”

Expanding coverage through Medicare and Medicaid will not be a panacea, however, because there remains a need to better understand which patients will derive the most benefit from the GLP-1 drugs, Kovacs said, noting, too, that prior authorization is a hurdle even in patients with currently approved indications.

“This is where we need to work together,” he said. “Where the government, CMS, specialty societies, patients, and all the providers need to work together to find out, first of all, who are the right patients for this? Who’s going to benefit the most? And then being able to seamlessly get those therapies to the patients that need it.”

It’s unclear how this proposal will fare after President-Elect Donald Trump returns to the White House in January. But, Kovacs said, “regardless of who’s in the White House, who’s in control of CMS, we should work together for better outcomes for our patients.”

CMS is accepting public comments on the proposed rule change, and other potential modifications, until January 27, 2025, through the Federal Register.