by Russell Noga | Updated January 6th, 2024
Does Medicare Cover Wegovy for Weight Loss?
Obesity is a prevalent issue that affects millions of people worldwide.
The search for effective weight loss solutions is ongoing, with many individuals seeking assistance from medications to help them achieve their goals.
A relatively new option on the market is Wegovy, a GLP-1 medication designed for weight management. But the question remains: does Medicare cover Wegovy for weight loss?
In this blog post, we will explore the ins and outs of Wegovy, Medicare’s stance on weight loss medications, and the ongoing debate surrounding Medicare coverage for weight loss drugs.
We will also discuss potential financial assistance options for those seeking help with the costs of Wegovy and other weight loss medications.
- Medicare does not cover Wegovy for weight loss due to restrictions imposed by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
- Individuals must explore alternative medications or seek financial assistance to cover the cost of Wegovy out-of-pocket.
- The debate over expanding Medicare coverage for weight loss drugs is ongoing with potential challenges but advocates are pushing for change in order to improve access and public health outcomes.
Understanding Wegovy and Its Uses
Wegovy is a GLP-1 medication primarily indicated for weight management. Unfortunately, Medicare does not cover Wegovy for weight loss purposes due to the FDA’s restrictions on the coverage of weight loss medications.
The primary goal of Wegovy is to help individuals lose weight, with the FDA approving its use for those with a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition.
For optimal effectiveness in weight loss, it is advised to use Wegovy in conjunction with a diet low in calories and increased physical activity.
The potential benefits of using effective weight loss drugs like Wegovy and Ozempic include reducing the risk of heart disease and stroke, as well as providing additional health benefits to individuals whose medical conditions are exacerbated by excess weight.
Regrettably, FDA limitations on weight loss medication coverage bar Medicare beneficiaries from accessing this potential game-changer of a treatment for losing weight.
Medicare’s Stance on Weight Loss Medications
The exclusion of weight loss medications from prescription drug coverage, specifically Medicare coverage, can be traced back to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Medicare Part D plans are explicitly prohibited from covering drugs prescribed for:
- weight loss or weight gain
- cosmetic purposes
- fertility treatments
- hair growth
- medications associated with sexual or erectile dysfunction
Consequently, Medicare beneficiaries don’t have coverage for weight loss medications such as Wegovy.
This exclusion extends to GLP-1 agonists like Wegovy, which are not covered by Medicare for weight loss due to the 2003 law.
While Medicare does not provide coverage for weight loss medications, it does offer coverage for weight loss counseling for eligible individuals.
Unfortunately, this leaves many individuals without access to potentially effective weight loss treatments like Wegovy, which can be a significant financial burden for those who may benefit from its use.
The FDA’s stance on weight loss medication coverage is based on the restrictions it has placed on these medications.
This has led to the current situation where Medicare beneficiaries are unable to access potentially life-changing weight loss treatments like Wegovy, leaving them to seek alternative solutions or face the financial burden of paying for these medications out of pocket.
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Coverage Details: Is Wegovy Covered by Medicare?
In brief, Medicare does not cover Wegovy for weight loss purposes. The annual cost of the medication is not covered, leaving individuals to explore other avenues to access this weight loss drug.
Medicare Part D prescription drug plans do not cover weight loss medications for cosmetic purposes, such as morbid obesity. This is stated in the Medicare Prescription Drug Benefit Manual.
Original Medicare Parts A and B, as well as Medicare Part D prescription drug plans do not offer financial coverage for Wegovy. Therefore, individuals are required to cover medical expenses related to this on their own.
However, Medicare does cover weight loss counseling for eligible individuals. This leaves many individuals without access to potentially effective weight loss treatments like Wegovy, and they must seek alternative solutions or face the financial burden of paying for these medications out of pocket.
Medicare Part D and Wegovy
Medicare Part D does not offer coverage for Wegovy, a weight loss drug. In order for prescription drugs to be covered under Medicare Part D, they must be FDA-approved, prescribed by a healthcare provider, and included in the plan’s formulary.
Furthermore, Part D plans are mandated to provide coverage for all drugs in the six protected classes, which include immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.
However, weight loss drugs like Wegovy are not part of these protected classes and are therefore excluded from coverage due to a federal ban.
This exclusion also applies to other weight loss drugs such as Ozempic and Mounjaro, which are not covered by Medicare Part D.
The lack of coverage for these potentially effective weight loss treatments leaves many individuals without access to the medications they need, forcing them to seek alternative solutions or face the financial burden of paying for these drugs out of pocket.
Medicare Advantage Plans and Wegovy
Medicare Advantage plans are private health insurance plans approved by Medicare that provide coverage for hospital, medical, and prescription drug services.
However, it is important to note that Medicare Advantage plans do not currently cover Wegovy. Whether to include or exclude a drug like Wegovy in a Medicare Advantage plan’s formulary hinges on factors like the drug’s cost, its effectiveness in treating the intended condition, and its potential impact on Medicare’s budget.
Additionally, the availability of alternative treatments and the recommendations of medical experts and regulatory bodies may be considered in making the decision.
The Medicare Advantage formulary is updated annually, which means that there is the possibility of future changes in coverage for drugs like Wegovy.
Individuals must keep abreast of potential updates to Medicare Advantage plans to guarantee they have the most current coverage information.
Medicare Supplement (Medigap) Plans and Wegovy
Medicare Supplement (Medigap) plans are health insurance policies offered by private insurance companies to supplement the insurance coverage provided by Original Medicare.
These plans assist with out-of-pocket costs such as deductibles, copayments, and coinsurance. They are guaranteed renewable, meaning that policyholders can maintain their coverage as long as their premiums are paid, regardless of health issues.
However, Medigap plans do not provide coverage for Wegovy, as Medicare is prohibited from paying for weight loss drugs like Wegovy due to the Medicare Modernization Act’s explicit exclusion of coverage for weight loss drugs.
As a result, individuals seeking Medicare coverage through Medicare Supplement plans will not find assistance, leaving them to explore alternative options or face the financial burden of paying for the medication out of pocket.
Ozempic and Other Weight Loss Drug Alternatives
An alternative to Wegovy is Ozempic, another GLP-1 medication that is FDA-approved for diabetes treatment. While Ozempic has gained popularity for its potential weight loss benefits, it is important to note that Medicare covers Ozempic for diabetes treatment, not for weight loss purposes.
Like Wegovy, Ozempic is a GLP-1 medication and is part of a new class of medications that physicians may prescribe to aid in weight loss.
Individuals seeking coverage for weight loss drugs like Wegovy and Ozempic may find limited assistance through Medicare, as the coverage restrictions for these medications are based on their primary indications.
This leaves individuals to explore alternative medications for weight loss or seek coverage for these drugs through other means, such as private insurance or financial assistance programs.
Financial Assistance Options for Wegovy
For those on the lookout for financial aid for Wegovy, there are a few potential options to consider.
Retiree health insurance plans, pharmaceutical assistance programs, and other resources may offer help with the costs of weight loss medications like Wegovy.
To qualify for coverage through retiree health insurance plans, individuals must meet a certain Body Mass Index (BMI) and participate in a weight loss coaching program.
Pharmaceutical assistance programs may also provide help with the costs of weight loss medications, but eligibility requirements typically align with FDA-approved use.
Drug manufacturers like Novo Nordisk and Eli Lilly offer savings programs for medications like Wegovy and Mounjaro, respectively.
These programs may help reduce the financial burden of paying for weight loss medications out of pocket. But it’s crucial to investigate all possible options and seek advice from healthcare professionals to find the financial aid best suited to personal circumstances.
The Debate Over Medicare Coverage for Weight Loss Drugs
The discussion surrounding Medicare coverage for weight loss drugs is complex and ongoing. It encompasses:
- The potential cost implications of providing coverage for anti-obesity drugs
- The primary arguments presented by proponents of extending Medicare coverage for anti-obesity drugs
- The Inflation Reduction Act, a proposed legislation, which may be able to address the cost concerns associated with extending Medicare coverage for weight loss drugs.
Manufacturers of GLP-1 agonists, legislators, and supporters of obesity treatment are advocating for a legislative change to enable coverage under Medicare.
As research has demonstrated that GLP-1 medications can lead to significant weight loss and may present additional health advantages to individuals with medical conditions exacerbated by excessive weight.
The debate continues, with the potential cost implications and points raised by supporters of expanded coverage requiring careful consideration.
Advocates for Expanding Coverage
Proponents of expanding Medicare coverage for weight loss drugs, including manufacturers like Novo Nordisk, legislators, and supporters of obesity treatment, argue that doing so could reduce obesity disparities and improve overall health outcomes.
By including weight loss drugs like Wegovy in Medicare coverage, more people, particularly those from disadvantaged backgrounds, can access these medications, leading to better weight management and improved health outcomes.
This extended coverage can help address disparities in obesity treatment and contribute to reducing the overall burden of obesity in the population.
However, expanding Medicare coverage for weight loss drugs also presents potential challenges and concerns. High costs, potential side effects, and concerns about access and equity all play a role in the ongoing debate surrounding Medicare coverage for weight loss drugs.
Despite these challenges, advocates for expanding coverage continue to push for change, highlighting the potential benefits for individuals struggling with obesity and the potential for improved public health outcomes.
Challenges and Concerns
One significant concern associated with expanding Medicare coverage for weight loss drugs is the high cost of these medications. Some examples include:
- Wegovy, which costs $1,000 or more per month out of pocket
- Ozempic, which also costs $1,000 or more per month out of pocket
- Mounjaro, which also costs $1,000 or more per month out of pocket
The potential impact on Medicare’s budget is an important consideration in the ongoing debate over coverage for these drugs.
Another concern is the potential side effects associated with weight loss medications like Wegovy, Ozempic, and Mounjaro, which may include:
- Abdominal discomfort
- Gastrointestinal issues
Balancing the potential benefits and risks of these medications is a crucial part of the ongoing conversation surrounding Medicare coverage for weight loss drugs, especially as more people seek to cover weight loss drugs through their insurance plans.
Strategies for Successfully Navigating Medicare Coverage
Navigating Medicare coverage successfully may require employing several strategies. Researching alternative medications, seeking financial assistance, and staying informed about potential changes in coverage can help individuals make the most of their Medicare benefits.
Consulting with healthcare professionals, utilizing Medicare resources, conducting online research, and joining support groups or online communities can all help explore alternative medications and potential coverage options.
Additionally, seeking financial assistance through programs like retiree health insurance plans or pharmaceutical assistance programs can help offset the costs of weight loss medications not covered by Medicare.
Keeping abreast of potential changes in coverage and investigating all resources at their disposal, individuals can optimize their Medicare benefits and get the weight loss treatments they require.
In conclusion, Medicare does not currently cover Wegovy for weight loss purposes, leaving individuals to explore alternative options for coverage and financial assistance.
The ongoing debate surrounding Medicare coverage for weight loss drugs raises important questions about the potential benefits and challenges associated with expanding coverage for these medications.
By staying informed about potential changes in coverage, researching alternative medications, and seeking financial assistance, individuals can navigate the complexities of Medicare coverage and access the weight loss treatments they need.
As the conversation around Medicare coverage for weight loss drugs continues, it will be essential to consider the potential benefits and challenges associated with expanding coverage for these medications.
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Frequently Asked Questions
Will Medicare ever pay for Wegovy?
Unfortunately, Medicare does not cover Wegovy or any other medicines for weight loss due to a 2003 FDA restriction. Some select Medigap and Medicare Advantage plans may offer coverage for weight loss medications, so if you have one of these plans it’s worth checking with its administrator.
What weight loss drug is covered by Medicare?
Medicare is prohibited from covering weight loss drugs, but covers Ozempic, an FDA-approved diabetes drug that’s unintentionally become popular for weight loss. Medicare Part D covers Ozempic for diabetes, not for obesity.
What is the criteria for Wegovy to be covered by insurance?
In order to be eligible for coverage with Wegovy, you must have a BMI of at least 30 or a BMI of 27 with one weight-related medical condition.
What is a less expensive alternative to Wegovy?
Orlistat is a less expensive alternative to Wegovy, costing between $500-800 compared to Wegovy’s price tag of $1,500. Many manufacturers also offer saving cards and patient assistance programs (PAPs) which can further reduce the cost.
Why doesn’t Medicare Part D cover Wegovy?
Medicare Part D does not cover Wegovy as it falls under the federal ban on coverage for weight loss drugs.
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.