INSURASALES

CMS Revisits GLP-1 Drug Coverage for Obesity in Medicare, Medicaid Pilot

The Centers for Medicare and Medicaid Services (CMS) is reconsidering coverage for GLP-1 drugs targeting weight management and obesity through a potential five-year pilot program. This program would allow individual state Medicaid and Medicare Part D plans to voluntarily cover drugs such as Novo Nordisk's semaglutide brands Ozempic and Wegovy, and Eli Lilly's tirzepatide drugs Mounjaro and Zepbound specifically for weight management purposes.

The move signifies a shift from the Trump administration's earlier decision to exclude obesity medications from Medicare coverage, reversing a Biden-era proposal initially introduced in late 2024. CMS has indicated that all drug coverages undergo cost-benefit reviews and has not confirmed the pilot but is considering future policy options on anti-obesity medications based on updated clinical evidence and fiscal impact assessments.

Pharmaceutical companies involved in this market, including Eli Lilly and Novo Nordisk, have responded to past coverage exclusions by obtaining approvals and CMS coverage for additional indications such as sleep apnea and cardiovascular risk reduction related to their obesity drugs. This evolving coverage landscape is significant for stakeholders including state Medicaid agencies, insurers, and patients managing chronic obesity conditions, highlighting regulatory and market dynamics impacting access to GLP-1 therapies.