Does Medicare Cover Wegovy, Zepbound, and Other Weight-Loss Medications?

Overweight and obesity are among the most important issues affecting health of population in the United States, especially of the elderly. More than one third of population has a body mass index (BMI) that is classified as “obese” which is a risk factor for high blood pressure, Type 2 diabetes and increased risk of developing the disease or dying from it. 

Some of the drugs include Ozempic (semaglutide), Wegovy (semaglutide) and Zepbound (tirzepatide) which are used in weight loss. However, their cost and average price of more than a thousand dollars monthly make it difficult for an iTndividual without insurance to afford them. 

If you are one of the Medicare beneficiaries, you can be curious about the coverage of these medicines. However, existing laws still generally prevent Medicare from paying for weight-loss drugs unless aimed at other recognised disorders, for example, cardiovascular disease.

Why Doesn’t Medicare Cover Weight-Loss Medications?

Medicare, the federal health insurance program for individuals 65 years and over, does not pay for the drugs used for weight loss only. The policy originated from the Medicare Prescription Drug, Improvement and Modernization Act 2003 in which Medicare Part D banned the coverage of drugs used in weight loss or weight gain. Such limitation is due to the perceptions that were held in the 1990s regarding treatments for obesity being ineffective and potentially dangerous.

Since 2013, when the American Medical Association classified obesity as a chronic disease there have been efforts to pass legislation such as the Treat and Reduce Obesity Act, which aims at extending Medicare coverage for obesity treatment including drugs.

What Medications Are Eligible for Medicare Coverage?

There are certain medications that Medicare does pay for when used for purposes other than weight loss such as controlling diabetes or decreasing risk factors of heart disease. Below is an overview of common weight-loss-related medications and their coverage details:

1. Ozempic

Use: It was approved for use in Type 2 diabetes in 2017.

Medicare Coverage: Available under Part D for the control of diabetes. Not covered if used for weight loss despite off-label approval.

Cost: If no insurance, brace to pay $1,000-$1,200 per month for treatment. Savings programs may lower price for non-Medicare customers to $ 25 per prescribed medicine.

2. Wegovy

Use: Being a recently approved drug for chronic weight management in 2021.

Medicare Coverage: Not covered for weight loss. However, since March 2024, it is included for patients with cardiovascular diseases, to protect them from heart attacks or strokes.

Cost: While for privately insured patients savings cards can make the price as low as $0, the uninsured may spend more than $1,300 for 28 days’ worth of treatment.

3. Mounjaro

Use: It has been approved by the end of the year 2022 for Type 2 diabetes.

Medicare Coverage: Again covered for diabetes but most often excluded when used for weight loss.

Cost: Savings cards may allow non-Medicare patients to pay only $25. The additional charges come at an average of $1,001 to $1,200 monthly in out of pocket expenses.

4. Zepbound

Use: It was approved by November 2023 for the chronic weight management.

Medicare Coverage: Currently it is not permitted to be participated in the Medicare services.

Cost: The cost depends on the type and the amount needed, however the basic package will cost you $1,060 for a 28 day’s supply. Savings programs could be less expensive for such recipients of private insurance.

Possible Solutions for Managing the Costs of Weight-Loss Drugs

If your medications are not covered by Medicare, you can explore several resources to manage their high costs:

1. Manufacturer Assistance Programs: Some companies such as Novo Nordisk, offer assistance to patients and in this regard, they offer assistance on drugs including Ozempic.
2. HSA or FSA Accounts: Prescription medications may be purchased with Health Savings Account (HSA) or Flexible Spending Account (FSA) funds, despite the funds available in a Flexible Spending Account are used up yearly.
3. State Medicaid Programs: Most of the states have criteria regarding the use of weight-loss medications and in states like California, Medicaid pays for medications available in the preferred drug list of Medicaid without prior authorization.

Do Other Insurance Plans Cover Weight-Loss Medications?

Weight loss medications are best bought with insurance however insurance differs from plan to plan and they may sometimes cover merely some of the medications. For 2024, 25% of employers have included GLP-1s, such as Ozempic and Wegovy, in their list of covered drugs, with many expectant of offering wider coverage next year. 

Most state-funded Medicaid programs also offer weight-loss drugs, although it is not standard. For instance, California has added these medications to its Medicaid preferred drug list and does not require prior authorization for those medications.

Even so, if your insurance plan does offer coverage, terms may differ. Consider asking your provider these key questions:

• Which classes of weight-loss medications are permitted?
• Is there any condition that must be met in order to qualify for selection?
• Does prior authorization matter?
• Is there coverage of weight-management programmes?
• How does one appeal if coverage is denied?

The Future of Medicare Coverage for Weight-Loss Medications

The advocates are hopeful of changes in policies that may see expansion of Medicare’s coverage. As the understanding of obesity continues to grow as a real health issue, future legislation may help to finally close the gap regarding providing accessibility for seniors. 

Until then, knowledge of existing policies and optimization of the existing savings programs can limit the load.

The Bottom Line

Wegovy, Ozempic, and Zepbound are the new promising drugs for obesity and its consequences. However, Medicare has not presently recognized these medications for weight-loss. It is only allowed for use in other conditions which they have been approved for like diabetes or prevention of cardiovascular diseases.

All that is left for seniors depending on Medicare to consider is other measures such as manufacturer savings programs or extra tools and services to make these treatments cheaper. It is anticipated that there are future legislative amendments that will allow for easier access to these transformational drugs someday.