CMS Proposes Rule to Cover Obesity Medications

In late November, the Centers for Medicare and Medicaid Services (CMS) officially proposed a rule to cover obesity medications in Medicare and Medicaid. Countless organizations have been working tirelessly to bring this change, but what has prevented the inclusion of these medications in the Medicare prescription drug program in the first place? Since the creation of Medicare Part D in 2003, the CMS has prohibited coverage of these drugs based on an outdated interpretation of a federal statute excluding “agents when used for anorexia, weight loss, or weight gain.” At the time of the passage of this statute, not only were there not any effective medications for treatment, but obesity was stigmatized and viewed as a lifestyle choice.  Obesity medications were considered cosmetics rather than as an appropriate treatment for a chronic disease. 

Interestingly, Medicare and Medicaid has covered the use of drugs used for weight gain   for the treatment of AIDS wasting and cachexia. In this case, CMS interpreted the statute to require coverage of such medications because the main purpose was to promote weight gain to mitigate the associated morbidity and mortality with AIDs. This precedent indicates that this statute can be suspended when the evidence supports that a drug’s primary function addresses a critical health issue.      

The proposed rule would allow Medicare and Medicaid to cover drugs used to treat obesity by reinterpreting the statutory language that prohibits their coverage . Coverage would be allowed for medications for the treatment of obesity when such drugs are listed to reduce excess body weight and maintain weight reduction long-term for individuals with obesity. This new interpretation recognizes obesity as a chronic disease rather than simply a lifestyle or cosmetic issue as historically interpreted. 

Since the establishment of the Medicare Part D program, the prevalence of obesity in the United States’ population has increased drastically from 30.5 percent in 1999-2000 to 41.9 percent in 2017-2020. The inclusion of these medications will benefit millions of people. 
CMS projects that approximately 3.4 million, or 7%, of Medicare beneficiaries would become newly able to access obesity medications under this reinterpretation if this proposal is finalized. This change could also dramatically decrease out-of-pocket costs for older Americans using these obesity medications, where a month's supply can cost up to $1,000. 

By extending access to obesity medications for people living with obesity who lack access to comprehensive evidence-based care in Medicare and Medicaid, the proposed rule would address an urgent health crisis. Without treatment, Medicare and Medicaid beneficiaries with obesity risk further health deterioration and an increased likelihoodin the onset of complications including obesity-related cancers, type 2 diabetes, and end stage renal disease. Additionally, people with severe obesity have a 48 percent higher risk of physical injury including falls which lead to higher costs and mortality rates.

CMS is accepting public comment on the proposed rule until January 27, 2025. Comments can be submitted here.