by Russell Noga | Updated January 31st, 2024
Is Mounjaro covered by Medicare? It’s a common concern for those prescribed this obesity medication. The coverage of Mounjaro by Medicare hinges on several factors, including the specific plan you have. Our article delves into the intricacies of Medicare plans and outlines the prospects for Mounjaro coverage, without overwhelming you with premature details.
Key Takeaways
- Medicare’s coverage for Mounjaro varies by plan type; however, Part D prescription drug plans are key in determining coverage, with financial assistance available through programs like the Mounjaro savings card or Optum Perks coupon.
- Medicare Part D explicitly excludes coverage for weight loss drugs, impacting access to treatments like Mounjaro (tirzepatide), thus leaving beneficiaries without financial support from Medicare for this specific use.
- The Inflation Reduction Act’s enactment might reduce medication costs, such as Mounjaro, by allowing Medicare to negotiate drug prices and introducing a rebate system that could help improve Medicare beneficiaries’ access to prescribed drugs.
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Navigating Medicare Coverage for Mounjaro
Understanding Medicare’s coverage for Mounjaro involves a closer look at different Medicare plan types. These primarily include Original Medicare, Medicare Advantage, and Medicare Supplement plans. Each one plays a distinct role in potentially providing coverage for Mounjaro, a crucial tool in the fight against obesity.
Original Medicare, or Part B, offers coverage for specific drugs. On the other hand, a Medicare Part D prescription drug plan is tailored to provide coverage for prescription drugs. Hence, Mounjaro’s coverage under a Medicare Part D plan depends on its classification.
While determining if their Medicare drug coverage includes Mounjaro, beneficiaries should compare premiums, deductibles, copayments, and other costs. A thorough review of the coverage options and provider networks is also advisable.
Additionally, Medicare Supplement plans can help cover expenses that Original Medicare does not, such as copayments, coinsurance, and deductibles.
Financial Considerations for Mounjaro Under Medicare
Understanding the financial aspects of Mounjaro coverage under Medicare is vital. The cost of Mounjaro for Medicare recipients is determined by the specific Medicare plan’s insurance coverage for the drug. Factors such as available savings programs and the patient’s insurance status can also impact the cost.
Without Medicare coverage, a one-month supply of Mounjaro is priced at approximately $974, while the retail price skyrockets to $3,108.63. These figures underline the significant role of Medicare coverage in making Mounjaro obtainable for those in need.
Fortunately, Medicare recipients can reduce expenses on Mounjaro prescriptions. Savings methods like the Mounjaro savings card program or presenting the Optum Perks coupon at the pharmacy could result in savings of up to 80%, even without insurance.
Brand-name drugs like Mounjaro often carry high costs, attributed to the extensive research and testing required for their development. This grants the manufacturer exclusivity in selling the drug for a period, which can extend up to 20 years. However, health insurance plans, including Medicare, may not always cover these high-cost drugs.
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Medicare's Stance on Weight Loss Drugs
Medicare’s coverage policies for weight loss drugs hold significant implications for Mounjaro. The legislation enacted in 2003, which established Medicare Part D prescription drug benefits, explicitly prohibits Part D plans from offering coverage for drugs intended for weight loss. This presents a hurdle for those hoping to have their Mounjaro prescription covered.
Specifically, GLP-1 agonists like Mounjaro (tirzepatide), which are prescribed for weight loss, are not included in the coverage provided by Medicare Part D. This leaves individuals seeking this treatment without the financial support of Medicare coverage.
Thus, policy interventions are crucial to address the affordability of treatments like Mounjaro under Medicare Advantage plans. Without such interventions, individuals may find themselves shouldering the full cost of their treatment.
The Inflation Reduction Act and Its Potential Effects on Mounjaro Coverage
Mounjaro costs for Medicare beneficiaries could potentially be influenced by the Inflation Reduction Act. This legislative proposal, introduced in the 118th Congress in July 2023, aims to empower the Secretary of Health and Human Services to negotiate drug prices on behalf of Medicare with insurance providers and drug manufacturers.
The Act grants the Secretary of HHS the authority to directly negotiate prices with manufacturers for specific high-expenditure drugs that lack generic or biosimilar competition. It also mandates manufacturers to provide a rebate to the federal government for prescription drug plans.
The Inflation Reduction Act has been enacted into law and is expected to create over 1.5 million additional jobs in the next ten years. Aiming to reduce overall healthcare costs, it facilitates Medicare’s negotiation for prescription drug prices and extends the expanded Affordable Care Act program for three years.
This could result in cost reduction for medications like Mounjaro, thereby improving Medicare beneficiaries’ access to anti-obesity drugs. The act also contains provisions aimed at reducing prescription drug expenses for Medicare recipients, including capping out-of-pocket spending at $35 per month for each insulin product covered under Medicare.
Maximizing Access to Mounjaro for Medicare Recipients
Several strategies can maximize Mounjaro access for Medicare recipients. One such strategy is the use of mail-order pharmacies. Medicare recipients can acquire Mounjaro by obtaining a prescription from their physician and placing an order through a designated mail-order pharmacy. The cost of Mounjaro may vary depending on the monthly premium and coverage of the specific Medicare plan.
Another strategy involves obtaining a 90-day supply of Mounjaro. With a valid prescription from a physician, Medicare beneficiaries can opt to purchase a 90-day supply. Some Medicare plans may cover the expenses for these medications when procured through mail-order pharmacies, which can be beneficial for patients with chronic conditions, such as end-stage renal disease.
Even without a specific cost comparison, obtaining a 90-day supply could help Medicare beneficiaries reduce their overall expenses. This can be particularly helpful for patients requiring ongoing treatment for conditions like obesity, as obesity services and medications can be costly.
Summary
We have journeyed through the complex landscape of Medicare coverage for Mounjaro, a promising weapon in the fight against obesity. Along the way, we’ve untangled the intricacies of various Medicare plans that may offer coverage for Mounjaro, explored the financial implications of Mounjaro coverage, and grappled with the legislative hurdles affecting the drug’s accessibility.
The journey doesn’t end here. As policy changes and new strategies emerge, our understanding of how to navigate Medicare coverage for Mounjaro will continue to evolve. Stay informed, stay proactive, and remember—you’re not alone on this journey.
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Frequently Asked Questions
How to get Mounjaro for $25?
You can get Mounjaro for $25 by using Lilly’s Mounjaro Savings Card if you have insurance. It starts at $25 for a 1- or 3-month prescription.
How much is Mounjaro out of pocket?
Without insurance, the average monthly cost of Mounjaro is between $1,000 to $1,200, but with commercial insurance, you could pay as little as $25 for a 1-month supply of the medication. If your insurance doesn’t cover Mounjaro, expect to pay about $900–$1,400 out of pocket for a monthly supply.
Will Medicare pay for Ozempic for weight loss?
Medicare will not cover Ozempic for weight loss, as it does not cover drugs prescribed specifically for weight loss. However, Medicare does cover Ozempic for the treatment of diabetes. Therefore, if prescribed for diabetes, it may be covered.
What are the different Medicare plan types that provide coverage for Mounjaro?
The main Medicare plan types that offer coverage for Mounjaro are Original Medicare, Medicare Advantage, and Medicare Supplement plans. Consider exploring these options for suitable coverage.
What are the factors influencing the cost of Mounjaro for Medicare recipients?
The cost of Mounjaro for Medicare recipients is influenced by factors such as the insurance coverage of the specific Medicare plan for the drug as well as available savings programs and the insurance status of the patient. Understanding these factors can help in managing the cost effectively.
Speak to the Professionals about Medigap Plans and Original Medicare
If you find understanding the benefits involved with Original Medicare and Medigap Plans challenging, you’re not alone. Whether it’s a Medigap plan, or you want to know more about Medicare coverage of Mounjaro, we can help. Call our team at 1-888-891-0229 for a free consultation or complete the contact form on this site, and an expert will call you back at a convenient time.
We have decades of experience advising our clients on the complexities of Medicare and Medigap plans, the benefits, cost and deductibles. We’ll ensure you get the best rate in your state and advice you can trust.
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.