https://www.forbes.com/sites/howardgleckman/2024/04/18/how-a-handful-of-drugs-is-squeezing-medicare/
The obesity crisis really is staggering in scale. I wonder how many of the people on Ozempic actually keep the weight off or if they just get trapped in a gain weight -> take drug cycle. And why wont they just do meth instead? Are they stupid? 
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This is slightly misleading as weight loss drugs are explicitly banned from Part D coverage 🤓
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Don't they just prescribe them as diabetes drugs rather than explicitly weight loss drugs, even if the outcome is obviously the same?
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Yeah but if they meet the medical criteria for pre diabetes it is okay??? It's not like some vanity 20lbs
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Yeah but they expand that criteria as much as possible, which the article discusses.
So there's a huge portion of the population that doesn't have and won't develop actual diabetes but can get diagnosed with "pre-diabetes" which they can then use to get weight loss drugs covered by Medicare as medically necessary. Given how very expensive these drugs are, it's not difficult to see how they could cause financial issues.
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I get what you're saying but idk that pbms are that generous tbh
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Yeah, the article doesn't really provide many numbers. For example, it doesn't detail what portion of people diagnosed with only pre-diabetes and are theoretically eligible to be prescribed ozempic and similar drugs are actually prescribed them. In fact the article itself seems mostly focused on a similar but more recent/novel situation related to Alzheimers.
tbh I have private insurance so I don't even know who makes the call for these public programs. If the doctor prescribes it, does Medicare have to pay? Can someone working for Medicare refuse coverage? Or is the person with that power not even employed by the federal govt?
It just seems like with public programs, there's a strong tendency to lean towards being more "open". It's easy for politicians to make rules that cause costs to increase since they're not actually on the hook for the payments. In other words, it's just really easy to spend somebody else's money.
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It gets complicated 🤗
It's actually always going to be harder on Medicaid or medicare to get smth approved.
Private insurance: generally covered unless it's truly a rly shit treatment. Almost always up to MD discretion (more or less).
For Medicare (old people), if it's FDA approved it's 95% of the time a covered benefit. The times it isn't is when there's a local or national coverage determination saying it's not worth it. Happy to discuss in detail if you have questions. This might be like it's $250k with only a 5% chance of improvement so they won't cover it. it depends on the part of the country for the specifics and for the specific drug & criteria. 99% of the time if it's FDA approved for a specific diagnosis, Medicare will pay.
For Medicaid they are FRUGAL AF. Even if it would make sense LONG TERM to approve a more expensive $$ drug they often will deny. For example, drug I'm currently working on isn't that cheap $ but also doesn't require people to switch to another biologic but in my state they still won't cover it. There are reasons for this….for example….medicaid is month to month so do u even care if in 5 years from now someone can't tolerate a med? They prob have private insurance or medicare at that point.
Medicare=the disabled after 2+ years and the poor. Medicaid=the extremely poor.
There are also specific provisions re: specific classes of drugs. I know you're kind of a generalist in technology but if you ever have questions about drug coverage lmk and I'll give u more details. Our reimbursement system is pretty complicated but truly we do a good job between innovation and covering poor people.
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keep yourself safe
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In my personal professional experience with biologics it's rly fricking hard to get pbms to pony up
for pre diabetes even less so??
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a 1/5 chance of getting diabetes means its a strong indicator
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I don't think so. Certainly not strong enough imo to justify having the federal govt spend tens of thousands of dollars per year on drugs for a condition they don't have but MIGHT develop sometime later.
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