Medicare coverage for Ozempic depends on several factors. These include whether an individual has diabetes along with obesity and whether their plan lists Ozempic on its list of approved drugs.
Semaglutide, known under the brand names Ozempic and Wegovy, is an injectable antidiabetic and weight loss drug. It is a class of medications known as glucagon-like peptide-1 (GLP-1) receptor agonists. Typically, a doctor will prescribe Ozempic to help someone living with type 2 diabetes (T2D) manage their blood sugar levels. It can also help reduce the risk of cardiovascular events in some people with diabetes and cardiovascular disease.
Ozempic works by acting like the gut hormone GLP-1, which signals to the brain that a person has eaten, reducing appetite. This produces more insulin, which removes glucose from the blood. Ozempic’s appetite-suppressing features may also lead to significant weight loss. This made the drug popular for non-medical reasons or cosmetic reasons.
Privately administered Medicare Part D plans and many Medicare Advantage plans cover specific medications for medically necessary reasons. As such, Medicare will only cover Ozempic if a person’s doctor confirms they need it to manage their blood glucose levels.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
If a person has a Medicare prescription drug plan, also known as Medicare Part D, they will have coverage for various medications. Depending on the plan, this may cover several medications that help manage blood glucose levels in people with T2D.
However, private insurers administer Part D plans in line with Medicare regulations and may choose their own formulary of approved drugs. A formulary is a list of drugs that a person’s Medicare plan will cover.
If a particular Part D plan’s formulary includes Ozempic and a doctor confirms someone with type 2 diabetes needs the medication to manage blood glucose, Medicare will pay for Ozempic up to Part D limits.
The cost to the Medicare enrollee depends on the tier at which the plan defines Ozempic. Higher-tier drugs, such as non-preferred, branded prescription drugs or specialty drugs, have the highest copayment.
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Medicare will only pay for FDA-approved uses of medications. It does not cover medications that people take for weight loss or weight gain alone.
Ozempic injections have approval from the FDA to
However, if a person does not have diabetes, Medicare will not pay for Ozempic. Medicare will only approve weight loss drugs for those with obesity that occurs alongside cardiovascular disease (CVD). It has not defined a particular level or type of CVD that qualifies someone for cover.
Medicare may cover Ozempic if a person requires it as a diabetes medication. In 2024, Medicare stopped excluding Wegovy from coverage to treat obesity occurring along with CVD. Previously, Medicare specifically excluded weight loss drugs from coverage, even when doctors prescribed them for medical reasons.
Wegovy has not yet received approval for diabetes drugs. However, the FDA
Medicare announced in March 2024 that Part D no longer excludes Wegovy as a treatment for people with CVD and a body mass index (BMI) of 27 or higher. This coverage would apply even if an individual does not also have diabetes.
Despite no longer being a general exclusion, an insurance provider may not include Ozempic or Wegovy on their prescription drug plan formulary. People can check their coverage documents for information on which drugs the plan includes and what copayment will apply.
Other insurers may include plans that someone funds privately or those that employers pay for. These plans may have different approaches to funding Ozempic and other weight loss drugs. Some may not pay for semaglutide medications at all, while others may only pay for semaglutide medications for people with diabetes or those with no co-occurring health problems.
For example, the International Foundation of Employee Benefit Plans surveyed employers’ health plans and whether they covered semaglutide drugs. The study found that 76 in 100 people had coverage for GLP-1 agonists if they had diabetes, while 27 in 100 individuals had coverage for GLP-1 agonists for weight loss alone.
People need to speak to their insurers or employer insurance team to define whether Ozempic is on their formulary, their terms for Ozempic coverage, the eligibility criteria, and any copay that applies.
Depending on a person’s Part D formulary, Medicare may fund Ozempic treatment in those with diabetes who need the drug to manage glucose levels. Medicare Part D may also fund Wegovy treatment to manage weight in people with both obesity and cardiovascular disease as of March 2024.
Private insurers administer Medicare Part D and Medicare Advantage prescription drug plans. Therefore, individuals need to speak with their providers about whether their formulary includes Ozempic and whether they are eligible for coverage.