Wegovy and Ozempic are popular medications known for helping with weight loss and diabetes management. Many people wonder if Medicare covers these drugs, especially for weight loss. Understanding Medicare’s rules can help you plan for treatment costs.
Both drugs contain semaglutide, but they’re used for different purposes. Ozempic is primarily for type 2 diabetes, while Wegovy is for weight management and heart health. Medicare’s coverage depends on why the drug is prescribed.
This article explains whether Medicare pays for Wegovy or Ozempic in simple terms. It covers eligibility, costs, and alternatives to help you navigate your options.
What Are Wegovy and Ozempic?
Wegovy and Ozempic are brand-name drugs containing semaglutide, a GLP-1 receptor agonist. Ozempic is FDA-approved for managing type 2 diabetes and reducing cardiovascular risks. Wegovy is approved for weight loss and heart disease prevention in people with obesity or overweight.
Both are weekly injections that work by mimicking a hormone that controls appetite and blood sugar. They’re often prescribed with diet and exercise. Their high cost makes insurance coverage a key concern.
While they share the same active ingredient, their approved uses differ. This affects whether Medicare will cover them. Always check with your doctor about which drug suits your needs.
Medicare’s Rules on Prescription Drug Coverage
Medicare Part D and Medicare Advantage plans cover prescription drugs. Each plan has a formulary, a list of covered medications. Coverage depends on the drug’s approved use and your plan’s rules.
Medicare is legally prohibited from covering drugs used solely for weight loss. However, drugs like Wegovy and Ozempic may be covered for other medical conditions. This restriction comes from the 2003 Medicare Modernization Act.
Check your plan’s formulary on Medicare.gov or your plan’s website. Contact your plan provider to confirm coverage details.
Does Medicare Pay for Wegovy or Ozempic?
Medicare’s coverage for Wegovy and Ozempic depends on the purpose of the prescription. Ozempic is typically covered under Medicare Part D for type 2 diabetes management. It’s also covered for reducing cardiovascular risks in some cases.
Wegovy is covered for preventing heart attacks and strokes in people with cardiovascular disease and obesity or overweight. However, Medicare does not pay for Wegovy or Ozempic when prescribed only for weight loss. Always verify with your plan, as coverage varies.
Prior authorization is often required. This means your doctor must submit paperwork proving medical necessity.
Eligibility for Wegovy Coverage
Medicare may cover Wegovy for adults with obesity or overweight and established cardiovascular disease. This is based on its FDA approval in March 2024 for reducing cardiovascular risks. About 3.6 million Medicare beneficiaries may qualify.
Your doctor must document your condition, such as a BMI of 27 or higher with heart disease. Prior authorization is usually needed. Check with your Medicare Part D or Advantage plan for specific criteria.
If prescribed for weight loss alone, Wegovy is not covered. Explore other covered treatments with your doctor if you don’t meet the criteria.
Eligibility for Ozempic Coverage
Ozempic is covered by Medicare Part D for type 2 diabetes management. It’s also approved for reducing cardiovascular risks in people with diabetes and heart disease. Your doctor must confirm these conditions for coverage.
Medicare does not cover Ozempic for weight loss or prediabetes, as these are off-label uses. An estimated 1.9 million beneficiaries with diabetes may qualify for Ozempic coverage. Always check your plan’s formulary for details.
Prior authorization may be required. Your doctor will need to provide medical records to support the prescription.
Costs of Wegovy and Ozempic with Medicare
The cost of Wegovy and Ozempic varies by Medicare plan. Wegovy’s list price is about $1,349 per month, while Ozempic is around $968. Out-of-pocket costs depend on your plan’s premiums, deductibles, and copays.
Medicare Part D plans may have copays ranging from $475 to $3,500 for Ozempic from May to December. Wegovy costs can be similar, depending on the plan and pharmacy. Use Medicare’s plan finder tool to estimate costs.
If uncovered, both drugs can cost over $12,000 annually. Patient assistance programs or coupons may help reduce expenses.
Sample Cost Breakdown
Here’s a sample cost breakdown for Wegovy and Ozempic under Medicare Part D:
| Drug | Condition | Estimated Copay (Annual) | Notes |
|---|---|---|---|
| Wegovy | Cardiovascular Risk | $500–$3,000 | Requires prior authorization |
| Ozempic | Type 2 Diabetes | $475–$3,500 | Varies by plan and pharmacy |
| Wegovy (No Coverage) | Weight Loss | ~$16,188 (full price) | Not covered for weight loss |
| Ozempic (No Coverage) | Weight Loss | ~$11,622 (full price) | Not covered for off-label use |
Costs are estimates and vary by plan. Check with your provider for exact figures.
Prior Authorization and How It Works
Many Medicare plans require prior authorization for Wegovy and Ozempic. Your doctor must submit evidence showing the drug is medically necessary. This includes diagnoses like diabetes or cardiovascular disease.
The process can take a few days to a week. If denied, you can appeal with additional documentation. Your doctor or pharmacist can guide you through the appeal process.
Check your plan’s requirements on its website or by calling customer service. Proper paperwork increases approval chances.
What If Medicare Doesn’t Cover Wegovy or Ozempic?
If Medicare doesn’t cover Wegovy or Ozempic, you have options. Discuss alternative medications with your doctor, like Mounjaro, which may be covered for diabetes. These alternatives might also cause weight loss.
Novo Nordisk offers a savings card through NovoCare.com, reducing Wegovy to $499 per month for some. GoodRx coupons can lower Ozempic costs to around $499 monthly. Check eligibility for these programs.
Non-drug options, like Medicare-covered behavioral counseling or bariatric surgery, may help with weight management. Your doctor can recommend the best approach.
Medicare’s Weight Management Alternatives
Medicare Part B covers obesity screening and counseling for beneficiaries with a BMI of 30 or higher. This includes weekly sessions for the first month, biweekly for months 2–6, and monthly for another six months if you lose at least 6.6 pounds. These services are free with no copay.
Bariatric surgery is covered for severe obesity if other treatments fail. This includes procedures like gastric bypass for eligible patients. Check with your plan for details.
These options can complement or replace drug-based treatments. Discuss with your doctor to see what’s covered.
Potential Changes to Medicare Coverage
In November 2024, the Biden administration proposed covering weight-loss drugs like Wegovy and Ozempic under Medicare and Medicaid. This could benefit 3.4 million Medicare users but was rejected by the incoming Trump administration for 2026. Coverage rules may evolve based on future legislation.
The Treat and Reduce Obesity Act, a bipartisan bill, aims to allow Medicare to cover weight-loss drugs. It hasn’t passed yet but could change coverage if approved. Stay updated via Medicare.gov for policy changes.
High costs raise concerns about premium increases. Medicare is negotiating prices for semaglutide, with savings starting in 2027.
Tips for Navigating Coverage
To check if Medicare pays for Wegovy or Ozempic, start with your plan’s formulary. Use Medicare’s plan finder tool at Medicare.gov to compare coverage. Contact your plan’s customer service for clarification.
Work closely with your doctor to document medical necessity. This strengthens your case for prior authorization or appeals. Keep records of all communications with your plan.
Explore manufacturer savings programs or GoodRx for cost relief. These can make uncovered prescriptions more affordable.
Summary
Medicare does not pay for Wegovy or Ozempic when used solely for weight loss due to legal restrictions. Ozempic is covered for type 2 diabetes and cardiovascular risk reduction, while Wegovy is covered for heart disease prevention in those with obesity or overweight. Costs vary by plan, often requiring prior authorization. Alternatives like counseling or surgery may be covered, and savings programs can help with costs. Always consult your doctor and plan provider to confirm coverage.
FAQ
Does Medicare pay for Wegovy or Ozempic for weight loss?
No, Medicare doesn’t cover Wegovy or Ozempic for weight loss alone. They may be covered for other conditions like diabetes or heart disease. Check your plan’s formulary for details.
Can Medicare cover Ozempic for type 2 diabetes?
Yes, Medicare Part D often covers Ozempic for managing type 2 diabetes. Prior authorization may be required. Confirm with your plan provider.
Is Wegovy covered for heart disease under Medicare?
Yes, Medicare may cover Wegovy for reducing cardiovascular risks in people with obesity or overweight and heart disease. Prior authorization is typically needed.
What are the costs of Wegovy and Ozempic with Medicare?
Copays vary, ranging from $475–$3,500 annually, depending on your plan. Without coverage, costs can exceed $12,000 yearly. Use Medicare’s plan finder for estimates.
What if Medicare denies coverage for Wegovy or Ozempic?
Appeal the denial with your doctor’s help or explore savings programs like NovoCare or GoodRx. Alternative treatments, like counseling or surgery, may be covered.