Understanding Medicare Coverage for Ozempic and Wegovy

In the world of health care, few topics have captured the public's attention quite like Ozempic and Wegovy. These semaglutide drugs, originally developed for different purposes, have become household names, driving a surge in demand that has sparked conversations in doctor's offices, on social media, and even in policy meetings. We know this is a silly question in some ways—they are two of the most sought-after drugs at the moment—yet we have also seen how their popularity is impacting the availability of actual diabetic medicines for those who truly need them, an issue that has been highlighted by a report from Indiana University School of Medicine's bioethics program.

This is a topic we've been tracking closely for our members, including in a recent meeting at the Baylor rollout where the issue was a big topic of conversation. These meetings, along with our constant communication with health care providers, are essential for staying up-to-date on the latest changes and ensuring our members' well-being. So, let’s clear the air and address the question that's on everyone's mind: "Will Medicare pay for Ozempic/Wegovy?"

The Straight Answer: It Depends on Why You Need It

The short answer is: it depends on your diagnosis. Medicare's coverage for these drugs is tied directly to their FDA-approved uses, which differ for Ozempic and Wegovy.

• Ozempic (semaglutide): This drug is FDA-approved to treat type 2 diabetes. As such, if your doctor prescribes Ozempic to manage your blood sugar levels, Medicare Part D (which covers prescription drugs) will generally provide coverage. In fact, most Medicare prescription drug plans cover Ozempic for this purpose.

• Wegovy (semaglutide): This drug is FDA-approved for chronic weight management. However, Medicare is currently prohibited by law from covering medications used solely for weight loss. The law, which dates back to the Medicare Modernization Act of 2003, excludes drugs for "anorexia, weight loss, or weight gain."

This is where the distinction becomes crucial. While Wegovy is a higher-dose formulation of the same active ingredient as Ozempic, its intended use for weight loss means that Medicare will not cover it for that reason. There is one exception: in March of 2024, the FDA approved Wegovy for a new use—to reduce the risk of major cardiovascular events in adults with heart disease who are also overweight or obese. In this specific scenario, a Medicare Part D plan may cover the drug.

How Medicare Covers Other Diabetic Drugs

For those with diabetes, Medicare provides comprehensive coverage for a wide range of medications and supplies. This is where the system truly shines, ensuring individuals have access to the care they need to manage their condition effectively.

• Medicare Part D: This is the primary source of coverage for most diabetes medications. It includes oral anti-diabetic drugs, as well as injectable insulin that is not used with a traditional insulin pump. For insulin, the Inflation Reduction Act of 2022 has capped the monthly out-of-pocket cost at $35 for those on a Part D plan, which is a massive benefit for millions of Americans.

• Medicare Part B: This part of Medicare covers certain medical supplies and services for diabetics. This includes things like blood glucose testing monitors, test strips, and lancets. It also covers insulin pumps and the insulin used with them, as well as diabetes self-management training and medical nutrition therapy.

The distinction between Parts B and D can be a bit confusing, but the takeaway is that a combination of these two parts of Medicare ensures that everything from insulin and testing supplies to doctor visits and educational training is covered.

The Larger Conversation

The explosive popularity of Ozempic and Wegovy has opened up a much larger conversation about the future of healthcare. As we discussed at the recent Baylor rollout meeting, the high demand for semaglutide is putting a strain on the supply chain for Ozempic, which can create shortages for people with type 2 diabetes who rely on the medication for blood sugar control. As the Indiana University School of Medicine report points out, this surge in off-label use for weight loss is leading to ethical challenges and accessibility issues for those with chronic diseases.

The high cost of these drugs is also a major factor. Without insurance, a single month’s supply can cost over $1,000. This is why our work is so important. We are committed to staying in constant communication with our network of providers and plans to ensure our members are always in the loop. We know that navigating the complexities of Medicare and prescription drug coverage can be daunting, but with the right information and advocacy, our members can make the best choices for their health and financial well-being.