Medicare May Cover Ozempic, But Not for Weight Loss

Semaglutide (brand name Ozempic) is a medication that was first developed to treat type 2 diabetes. While it was effective in controlling blood sugar, it was also found to decrease appetite and promote weight loss. One study found that people lost as much as 6% of their weight within three months and up to 11% in six months of taking it.

Unfortunately, Medicare covers this medication only in certain situations. For example, Ozempic is covered for the treatment of type 2 diabetes; it is not covered for the purpose of weight loss.

This article will discuss the conditions for which Medicare covers Ozempic, when it does not, and how to get savings on Ozempic if not covered by your health insurance.

When Does Medicare Cover Ozempic?

Medicare covers medications that it considers to be medically necessary. This includes most drugs approved by the Food and Drug Administration (FDA) for certain indications, which include a diagnosis, illness, injury, syndrome, or condition.

Ozempic is an injectable medication in the class of drugs known as glucagon-like peptide agonists (GLP-1 medications). It has an FDA-approved indication for type 2 diabetes and for cardiovascular-event reduction in people who have both type 2 diabetes (the body cannot properly regulate and use blood sugar as fuel) and known cardiovascular disease (conditions affecting the heart and blood vessels).

Many Medicare Part D plans will cover Ozempic for beneficiaries who have these conditions.

Off-Label Use

In some cases, medications are used off-label. This means a healthcare provider prescribes a medication for a different medical indication than approved by the FDA, or at a different dose, frequency, or administration.

The Centers for Medicare and Medicaid Services (CMS) may allow coverage for medications for off-label use if that treatment is accepted as reasonable care, if it has medical research to back it up, and if it is accepted as a standard of practice in the medical community.

Having obesity can increase your risk for a number of medical conditions, including heart disease, diabetes, and sleep apnea (breathing repeatedly stops and starts while sleeping), among others. For some people, lifestyle modifications like diet and exercise are not always enough to decrease those risks. That is why many people turn to medications like semaglutide to help with weight loss.

Reasons Medicare Won’t Cover Ozempic

When the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created Medicare Part D, it included a rule that medications could not be covered for cosmetic reasons or for the purposes of weight loss. This, unfortunately, limits how Ozempic is covered, and if you do not have type 2 diabetes, Medicare Part D will not cover it.

Incidentally, the MMA was passed before the American Medical Association (AMA) designated obesity as a disease in 2013.

With rising rates of obesity and obesity-related complications, the AMA in 2023 argued for coverage of obesity treatment. It stated, “The AMA will urge health insurers to provide coverage of available FDA-approved weight-loss medications, including GLP-1 medications, to demonstrate a commitment to the health and well-being of our patients.”

A 2023 analysis by the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California (USC) looked at the potential effects drugs like this could have on the healthcare system. They estimated that Medicare could save as much as $245 billion over 10 years if it expanded coverage to include weight loss treatments.

Although there is an upfront cost to using these medications, treatment targeted to weight loss would decrease obesity-related complications, treatments for those conditions, and the need for hospitalization. With more potential savings than spending, it is possible that Medicare could reconsider the decision to cover weight loss medications in the future.

How to Get Medicare to Pick Up Ozempic Cost

As a brand-name drug, Ozempic can be quite expensive. Novo Nordisk, the pharmaceutical company that makes the drug, notes that each Ozempic auto-injector pen costs a retail price of $937. Depending on the dose you take, you may have to pay more or less than this amount each month.

If you are fortunate enough to have insurance, your out-of-pocket costs could be much lower. This assumes your healthcare plan covers the drug.

Because the GLP-1 class of medications is more expensive than many other classes of antidiabetic drugs, your Part D plan may require your healthcare provider to verify why Ozempic is medically necessary for you before it will cover the drug. This is known as prior authorization.

Your plan may also require you to try other lower-cost medications first as a way to keep costs down. This is known as step therapy.

Speak with your healthcare provider to make sure that they have all the information needed for Medicare to cover Ozempic. A diagnosis of type 2 diabetes is essential, but a BMI calculation should be included in any documentation to your Part D plan to improve your odds of coverage.

Other Ways to Get Savings on Ozempic 

Novo Nordisk offers a savings card that can reduce the cost of Ozempic to as little as $25 per month. To take advantage of this program, you must have commercial insurance, and you cannot be on Medicare or Medicaid.

Because there are no savings opportunities for people who do not have insurance or for people using federal programs, equal access for all is not possible.

If you are on Medicare, you should determine if you qualify for the Part D Low Income Subsidy, referred to as Extra Help. This can decrease how much you pay for your medications in deductibles, coinsurance, or co-pays during the year. Thanks to the Inflation Reduction Act, more people will be eligible for the subsidy program in 2024.

All formulations of semaglutide, including the following, promote weight loss, not just Ozempic:

• Wegovy: It is an injectable version of semaglutide, but the medication comes in different doses than Ozempic. Because the drug is FDA-approved for weight loss, it is not covered by Medicare, but you may be able to acquire discounts through the manufacturer.
• Rybelsus: This brand of semaglutide is taken by mouth, not injection. With an FDA-approved indication for diabetes, it may be covered by your Medicare Part D plan. The amount of predicted weight loss is comparable to the injectable versions. Discounts are also available through Novo Nordisk for people who have commercial insurance but not for those on Medicare or Medicaid.

Summary

Ozempic and other GLP-1 medications are effective weight loss medications that may or may not be covered by Medicare Part D. Because current legislation does not allow Medicare Part D to cover weight loss medications, these drugs will only be covered when they are used to treat diabetes.

That could change as professional organizations lobby for coverage of weight-loss medications by Medicare in the future.