White House rule would expand coverage of anti-obesity drugs

WASHINGTON — The Biden administration on Tuesday proposed expanding drug coverage under Medicare and Medicaid to include anti-obesity drugs — a move rebuking Robert F. Kennedy Jr.’s critique of the popular medications.

The proposed rule from the Department of Health and Human Services seeks to expand when Medicare and Medicaid can cover anti-obesity drugs known as GLP-1 inhibitors, sold as Zepbound, Ozempic, Mounjaro and Wegovy.

The obesity drug coverage changes were part of a larger proposed rule that also would make changes to prior authorization, provider directories and beneficiary protection.

Currently, Medicare covers the weight-loss drugs in question for beneficiaries diagnosed with diabetes or cardiovascular disease who are also classified as overweight or obese. All state Medicaid programs cover the drugs for patients with diabetes, but only about a quarter cover the drug for weight management.

Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure said the proposal reinterprets Medicare statute to cover these medications not as weight-loss drugs but as drugs to manage the chronic condition of obesity.

“The medical community today agrees that obesity is a chronic disease,” Brooks-LaSure said in a call with reporters Tuesday. “During my time as CMS administrator, I have heard from countless people about how this coverage exclusion is a barrier preventing people from treating obesity and living healthier lives.”

CMS said the interpretation followed a precedent in 2010, when Medicare began covering facial injections for Medicare beneficiaries diagnosed with HIV-associated wasting syndrome and depression.

Nearly three-quarters of U.S. adults 25 or older qualify as overweight or obese, according to data published in The Lancet earlier this month. The study projects that number will increase to 80% by 2050 without counteraction.

While the newer obesity drugs can reduce some of the negative outcomes associated with chronic obesity such as heart disease, diabetes, stroke and premature death, their high price tag can be a prohibitive factor for many individuals.

Without insurance, the drugs could run as much as $1,000 per month out of pocket. CMS estimates that the finalized rule would open up coverage for 3.4 million Medicare beneficiaries and 4 million Medicaid enrollees. Children who are 12 and older who meet the guidelines for obesity and are covered by Medicaid would be eligible for coverage.

The agency estimates that it would cost the federal government $25 billion to pay for the expanded Medicare prescription drug coverage. For Medicaid, the proposal would cost the federal government $11 billion and states about $3.8 billion, said Dan Tsai, CMS deputy administrator and director for the Center for Medicaid and CHIP Services.

“The federal government will cover more than the majority of the cost,” said Tsai, acknowledging that states are “feeling substantial state budget pressure.” “We would urge drug manufacturers to do their part as well, make sure they’re thinking about offering fair, appropriate prices to the Medicaid program all across the country.”

The Congressional Budget Office estimated in October that a policy authorizing Medicare to cover these drugs would increase federal spending by about $35 billion between 2026-2034.

Congress has taken some preliminary action to expand access to the drugs under Medicare.

In June, the House Ways and Means Committee advanced a bill that would allow Medicare to cover the drug for patients who had already been prescribed and taken the drug rather than to all Medicare beneficiaries.

Lawmakers also asked HHS to use its “existing legal authority” to lower the prices of these drugs in September. During a Senate Health, Education, Labor and Pensions Committee hearing in September, the CEO of Novo Nordisk, which manufactures Ozempic, blamed insurers and pharmacy benefit managers for the high cost to consumers for these drugs.

The proposed rule asks for feedback on timing for implementation from states, meaning it could only be finalized during the next administration.

Kennedy, a noted vaccine skeptic and President-elect Donald Trump’s expected nominee to lead HHS, has called for reducing chronic illness and increasing oversight into processed foods.

But he’s also been a sharp critic of anti-obesity drugs and possible side effects.