CMS urged to change GLP-1 drug coverage determination

Healthcare organizations are continuing to push the Centers for Medicare & Medicaid Services (CMS) to rethink its coverage policy for anti-obesity medications.

These medicines are not covered by Medicare Part D, because existing statutory exclusion is in place for these drugs that do not cover “agents when used for anorexia, weight loss or weight gain,” according to a press release. In a joint press conference hosted by health experts at Manatt, Phelps & Phillips and the Obesity Action Coalition, advocates laid out a legal basis in support of covering GLP-1s, stating that they can target obesity rather than describing the drugs solely in terms of their effects on weight.

“Obesity is a disease that has multiple causes and consequences not limited to weight,” said Michael Kolber, a healthcare partner at Manatt Health, to reporters. “There are many drugs that cause weight loss or weight gain, even if that’s not why they’re being prescribed.”

Kolber said GLP-1s can serve several purposes, including treating obesity. Obesity is largely considered a chronic disease, making CMS’ interpretation regarding the condition outdated.

He noted that a drug like serostim, which HIV patients use to treat wasting or cachexia to increase body mass and weight, is covered by CMS. The drug’s coverage predated the Medicare Part D program, but the same statutory language applies to Medicaid.

Instead, Kolber said CMS’ current approach is “arbitrary” and doesn’t reflect “reasoned policy” in that it covers some treatments for obesity, such as bariatric surgery, but not other treatments. Incorporating anti-obesity medications into Medicare Part D does not mean health plans would be required to cover drugs under cosmetic or non-medically necessary uses, but encouraging use of these drugs would align with recent FDA drug approvals, President Joe Biden’s Cancer Moonshot initiative and other health equity priorities that can be addressed by tackling obesity, he argued.

“It's simply a decision that was made now more than 30 years ago by Congress, when the landscape of obesity treatment and the understanding of obesity as a disease was quite different,” said Kolber.

Other federal agencies, including the Social Security Administration, the National Institutes of Health and the IRS, already consider obesity a disease, while the Department of Defense and the Department of Veterans Affairs provide coverage for anti-obesity medications. These FDA-approved medicines are covered by 17 states in fee-for-service Medicaid.

“Obesity is a chronic condition resulting from a combination of genetic, environmental, behavioral, social and other factors,” said Tracy Zvenyach, Ph.D., director of policy strategy and alliances at the Obesity Action Coalition, adding that treating obesity can help treat adverse side effects and help reduce stigma people may face in everyday life. “Approximately 1-3% of people have access to evidence-based scientific obesity treatments.”

She explained that CMS can improve access to care for older Americans, which can influence how health payers determine coverage policies.

The white paper also calls on the Food and Drug Administration to update guidance surrounding stigmatizing language on the topic, said Manatt Health Partner Rachel Sher.