Less than 2 weeks after FDA approved the new indication (semaglutide is also approved for chronic weight management and type 2 diabetes), CMS issued a memorandumopens in a new tab or window stating that Medicare Part D plans may cover AOMs if they are FDA approved for an additional medically accepted indication beyond only weight management. CMS' guidance is prospective and is not limited to semaglutide. The guidance applies to all AOMs that may be approved in the future to treat other conditions. To ensure that AOMs are used for medically accepted indications, CMS clarified that Part D sponsors may employ common utilization management tools like step therapy and prior authorization.
Notably, FDA's approval of semaglutide for cardiovascular disease is likely a harbinger of similar approvals in the near future -- along with their coverage by Medicare. While the benefits are substantial, so too may be the costs as more and more drugs and patients receive coverage.
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Notably, FDA's approval of semaglutide for cardiovascular disease is likely a harbinger of similar approvals in the near future -- along with their coverage by Medicare. While the benefits are substantial, so too may be the costs as more and more drugs and patients receive coverage.
Opinion | Medicare Can Cover Anti-Obesity Drugs for Heart Disease -- But at What Cost?
Intense demand coupled with high costs may place pressures on CMS for years to come
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