Wegovy is a weight loss drug now indicated to reduce the risk of heart attack and stroke. Medicare coverage for Wegovy through Part D prescription drug plans may vary.
Medicare Part D, prescription drug coverage, may pay for certain medications used to treat heart disease. However, there are limitations.
Wegovy is a medication to help treat obesity. Recent changes in its indications have affected insurance coverage, including Medicare.
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.
Medicare Part D may cover Wegovy for enrollees who have overweight or obesity and have heart disease. In March 2024, the Food and Drug Administration (FDA) approved a new indication for Wegovy.
The
In the past, Medicare did not cover antiobesity medications. It is helpful to understand that Wegovy coverage is still not available for weight loss itself. Criteria for coverage include a medically acceptable indication, which is a diagnosis of cardiovascular disease.
Medicare Part D provides coverage because Wegovy is a self-administered injectable medication. Medicare Part D provides coverage for self-administered drugs. Individuals who do not have a Medicare Part D drug plan will not have coverage through Medicare Part B, which covers physician-administered drugs.
This new indication for Wegovy may open up coverage for the drug to an estimated 3.6 million Medicare beneficiaries and possibly more, according to KFF.
People who have a Medicare Advantage plan instead of Original Medicare (parts A and B) should check with the plan administrator. Many Medicare Advantage plans offer prescription drug coverage, but the medications covered and associated costs may vary by plan.
Learn about Original Medicare vs. Medicare Advantage.
Why Medicare does not typically cover antiobesity drugs
The Medicare Modernization Act of 2003 prohibits Medicare from covering weight loss drugs. This act remains in effect, so Medicare will not cover Wegovy for people without a cardiovascular disease diagnosis.
The exact cost of Wegovy when covered by Medicare Part D may vary based on the specific prescription benefit offered. Medicare Part D plans may have different deductibles and copays.
Some plans may also cover Wegovy as a specialty or higher-tier drug, which allows the Part D plans to charge a higher copayment.
The general cost of Wegovy for people covered by Medicare Part D may include a monthly out-of-pocket expense of $325 to $430, which may be a percentage of the $1,300 list price.
Out-of-pocket expenses are the portion of the cost the individual is responsible for. Medicare caps out-of-pocket expenses at $3,300 to $3,800 in 2024 and $2,000 in 2025.
Wegovy is a glucagon-like-peptide-1 (GLP-1) receptor agonist, a class of obesity medications. Wegovy, which is the brand name, contains the active ingredient semaglutide.
Wegovy acts like a GLP-1 hormone, which works in the brain to regulate a person’s appetite. It also appears to slow down how fast food moves through the digestive system, making someone feel full longer. This combination helps reduce food and calorie intake, leading to weight loss and weight management over time.
Wegovy comes as a prefilled liquid solution that is self-administered via a single-dose injection pen.
Having overweight or obesity is a
Researchers continue to investigate the exact reason why Wegovy may help reduce heart disease. However, some studies indicate it may have certain protective mechanisms that reduce the risk of heart disease. For instance,
A 2023 double-blind placebo-controlled trial found that semaglutide was better than the placebo in reducing the incidence of nonfatal heart attack and stroke and the incidence of death from cardiovascular causes in adults with obesity who did not have diabetes.
If an individual does not have a diagnosis of heart disease, Medicare will not cover the drug for weight loss. However, other options may help someone get Wegovy.
Wegovy is currently only available as a brand-name medication. This means there is no generic option. Generic drugs have the same active ingredient as the brand-name medication and are usually less expensive.
However, cost-saving measures may be a possibility for people who do not have Medicare coverage for Wegovy. A person can consider the following options:
- Look for a savings card: One option may include enrolling in the Wegovy savings card program. This card is for individuals with or without insurance coverage. Information on a savings card is available on the manufacturer’s website.
- Check out other prescription discount cards: Various companies also offer prescription discount cards, which provide savings on medications.
- Try a mail-order pharmacy: The pharmacy you use may also affect the cost of Wegovy. A mail-order pharmacy may be less expensive than traditional pharmacies.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
The law prohibits Medicare from covering medications specifically for weight loss. However, the FDA expanded the indication for the weight loss drug Wegovy.
Guidance now allows Medicare Part D prescription plans to cover Wegovy to prevent heart attack and stroke in people who are overweight or obese and have a diagnosis of heart disease.
The exact cost of Wegovy to the individual may vary depending on the Part D plan. For people who do not have a diagnosis of heart disease and do not have coverage, cost-saving prescription cards may be an option for getting Wegovy.