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Part B News Quotes Paul Werner on Coverage for Ozempic and Wegovy

Buttaci, Leardi & Werner member Paul D. Werner was quoted in an article in Part B News titled “Be Careful of Patients Seeking Wegovy with Suspect Heart Complaints.” The article, published July 8, discusses insurance coverage for Ozempic and Wegovy (semaglutide), two injectable drugs that have garnered a lot of attention as weight-loss drugs.

Medicare doesn’t cover any drugs for weight loss alone, but Ozempic, which has received FDA approval as a treatment for diabetes, is covered by Medicare Part D for diabetes.

Wegovy has never been approved for diabetes, but in March, the FDA made an adjustment to its parameters indicating it can be used to “reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.” That opened the door to coverage by Medicare and other insurance.

The change has some providers concerned that patients might misrepresent their health to get Wegovy covered by Part D Medicare.

Werner said the semaglutide craze reminds him of “the big push a few years back to try to get certain bariatric surgical procedures covered for weight loss. There was some back and forth about whether it was being done for cosmetic purposes.”

“If providers who have never treated a patient for a cardiac issue are now, all of a sudden, identifying cardiac issues to be treated with Ozempic, that is potentially going to raise red flags,” Werner said. “Would it, in and of itself, set off alarms at Medicare or any other payer? Probably not, but if someone starts looking [at the provider] for some other reason and finds such a pattern, then maybe. I would tell my provider clients that if a patient comes in the door asking for a specific medication, you need to do some digging.”

The full article can be read at Part B News (subscription may be required).

  • Posted on: Jul 8 2024