January 9th 2024
By Ari Parker
A comprehensive guide to determine if Medicare covers Ozempic. Learn if you're eligible for coverage and what other Medicare options you have for diabetes and weight loss.
Ozempic is a drug that has sparked questions for people across the United States. While Ozempic is primarily used in treatment plans for people with diabetes, it's also commonly used as a weight loss drug.
Medicare covers Ozempic for diabetes treatment but not for weight loss. Medicare actually doesn’t cover any weight loss medications due to Medicare regulations and a focus on medically necessary treatments.
Read on to learn more about how Medicare covers Ozempic for the treatment of type 2 diabetes.
Medicare covers Ozempic for diabetes treatment but not for weight loss.
While Medicare doesn’t cover Ozempic or other prescription drugs for weight loss, it does cover obesity screenings and behavioral counseling for people with a BMI of 30 or more.
Ozempic is the brand name for semaglutide, which, when paired with a healthier diet and exercise, can improve blood sugar in adults with type 2 diabetes. It belongs to a category of drugs called GLP-1 medications that typically treat type 2 diabetes.
Ozempic has grown in popularity because it has also helped many people lose weight. That said, it’s important to note that Ozempic is not first and foremost a weight loss drug.
Doctors often prescribe Ozempic as part of a more comprehensive plan for people with type 2 diabetes. It’s particularly helpful for those who haven't been able to control their blood sugar with other medications and lifestyle changes.
Ozempic is a semaglutide that controls blood sugar by mimicking the action of a natural hormone called GLP-1, which plays an important role in regulating blood sugar.
In other words, Ozempic lowers blood sugar levels by helping to release insulin. It also reduces the amount of sugar produced by your liver. Lastly, Ozempic stabilizes blood sugar levels after eating by slowing your stomach as it empties.
As mentioned above, Ozempic has grown in popularity specifically because it has helped many people lose weight. The reason Ozempic has worked for some as a weight loss drug is because the regulation of blood sugar has an additional impact on appetite and food intake as an appetite suppressor.
Ozempic clearly states on its website that it is not a weight loss drug, and because this isn’t the intent of the drug, it won’t generally be covered by insurance if you do not have type 2 diabetes.
Medicare only covers Ozempic if the drug is used to treat diabetes. To reiterate, it will not cover the medication for chronic weight management. Medicare Advantage plans have to comply with the same regulations as Medicare, so these plans won’t cover Ozempic for weight loss either.
Ozempic is an outpatient prescription drug, so Medicare Part D would cover the diabetes medication. It’s a fairly popular drug for Medicare coverage—459,000 Medicare beneficiaries had Ozempic coverage in 2021.
Part D plans vary from person to person. It’s important to check your plan’s drug list, to see if your Medicare plan covers Ozempic.
If you don’t have Medicare Part D prescription drug coverage, you can get one as a standalone policy with Original Medicare or bundled with a Medicare Advantage plan.
It’s unlikely that Medicare will cover Ozempic for prediabetes. In most cases, your doctor won’t prescribe Ozempic unless you have a formal diagnosis for diabetes. However, Metformin is another prescription drug used to treat type 2 diabetes that can be prescribed for prediabetes. It isn’t specifically intended for prediabetes, but can help reverse prediabetes when paired with lifestyle changes.
100% of Medicare prescription drug plans cover Metformin, but there are limits to the quantity you can fill at one time. You’ll also need to check your plan’s formulary (list of drugs) to determine what you will pay for Metformin.
When not covered by Medicare, the cost of Ozempic is pretty high. The list price for Ozempic is $935.77 for a month’s worth of weekly doses, which is $12,200 for a whole year!
Unfortunately, Medicare, which is regulated by the federal government, doesn’t cover weight loss drugs because it considers the drugs used for weight loss to be cosmetic treatments. These rules against weight loss drugs were created a few decades ago. At that time, however, the weight loss drugs available were more dangerous. The health policy around obesity drugs may change, but it isn’t guaranteed.
Novo Nordisk, the same company that created Ozempic, also sells a drug called Wegovy. Unlike Ozempic, Wegovy is FDA-approved for weight loss. Medicare won’t cover Wegovy for weight loss, but Medicare will cover Wegovy if you have an increased risk of heart attack or stroke.
Make sure to check your prescription drug plan for Wegovy coverage if you meet the eligibility criteria.
Maintaining and losing weight after 60 can be challenging, and many find it difficult to find and stay on the right plan alone. Your risk of developing heart disease, cardiovascular disease, and high blood pressure increases with obesity, especially as an older adult. It’s important to take preventive measures to protect your health.
Although Medicare does not pay for any medications for weight loss, Medicare Part B does cover some preventive services related to weight loss.
Medicare covers weight-loss counseling if you have a BMI of 30 or higher. These sessions include a screening and regular face-to-face meetings with a medical professional to set up plans and check-ins around diet and exercise.
Medicare also covers some weight loss surgeries including gastric bypass surgery and laparoscopic banding surgery. You must meet strict requirements around morbid obesity to get these surgeries covered.
It’s important to work with your healthcare provider to understand what works for your weight loss goals. Your Annual Wellness Visit is a great time to ask questions and create a plan with specific goals with your doctor.
To sum it all up, Medicare helps with the cost of Ozempic if it's prescribed for treating diabetes, but not for weight loss. If you need Ozempic for diabetes, you should check your Medicare drug plan to see if it covers Ozempic.
If you have questions or need help understanding your options, talk to one of our licensed Medicare Advisors for free, personalized advice about your unique health needs. Give us a call at (855) 900-2427 or schedule a consultation today to get started.
