February 2nd 2024
By Ari Parker
Discover whether or not Medicare beneficiaries can access coverage for Wegovy, a new weight loss medication.
By Ari Parker
Many people are curious about a new weight loss drug called Wegovy. Made by the same company as Ozempic, Wegovy is an FDA-approved weekly injection for long-term weight management. Unlike Ozempic, which was developed to manage type 2 diabetes, Wegovy is specifically intended for weight loss.
Medicare does not cover any weight loss drug if the intended purpose is to lose weight. In these cases, your Part D prescription drug plan would not pay for Wegovy. However, Medicare will cover Wegovy if your doctor prescribes it to reduce your risk of heart attack and stroke. A recent study by KFF estimates that this means 25% of people on Medicare could be eligible for Wegovy coverage.
There are numerous reasons why Medicare doesn't cover weight loss drugs (stay tuned, we’ll go over them below), but there are other ways Medicare can cover weight management.
Medicare does not cover Wegovy or any other drug for the purpose of losing weight.
Medicare will cover Wegovy if you need it to reduce your risk of heart attack and stroke.
There are other services that Medicare does cover for weight management like weight-loss counseling and preventative care.
Wegovy is the first weekly injection for weight-loss medication approved by the FDA since 2014. Both Ozempic and Wegovy incorporate the same active ingredient, semaglutide, which helps with both type 2 diabetes and weight management. Semaglutide slows down the rate of your stomach emptying and makes you feel fuller after meals. Here are a few other ways the drug helps with weight loss:
decreases cravings for salty and sweet foods
counteracts hormones involved with hunger and weight gain
targets brain areas involved with appetite control
The weight loss journey can often be mentally and physically exhausting. Medications like Wegovy can help ease the frustration, but they aren’t the only option for weight management. We’ll look into some other alternatives, especially since Medicare doesn’t cover Wegovy.
Recent studies show that Wegovy also lowers the risk of stroke and heart attack in overweight or obese adults who don't have diabetes.
You may be confused about why Medicare doesn’t cover Wegovy or any drug specifically intended for weight loss. Numerous studies have shown that obesity can contribute to serious health conditions like cardiovascular disease, high blood pressure, and diabetes. If obesity poses such a risk on your health, why wouldn’t Medicare cover drugs for weight loss management? There are a couple factors that answer this question:
Medicare currently considers weight loss drugs to be cosmetic. Medicare doesn’t cover any procedure, service, or drug for cosmetic purposes.
Medicare doesn’t cover any medications that could be abused or used for another purpose.
Lawmakers confirmed Medicare’s regulations on covering obesity treatments in the 1990s, when weight-loss drugs were less effective and more dangerous.
It’s true that some Medicare laws and regulations are outdated. There are legislations about Medicare coverage that are constantly changing. Medicare may choose to provide better coverage for obesity medication and treatment in the future, but the program doesn’t cover drugs for weight loss as of now.
While Medicare doesn't cover Wegovy for weight loss, you can get coverage for the drug if you're at a higher risk of strokes or heart attacks.
Without insurance, Wegovy is pretty expensive. The weight loss medication is $1,349 per package for a month’s supply. That means Wegovy costs $16,188.24 out of pocket for a full year.
Since the FDA approved Wegovy for lowering heart risks, private insurance companies are more likely to cover the drug for this intended purpose. Check whether or not your insurance covers Wegovy if you have health coverage through your employer or another means.
Medicaid covers Wegovy to prevent heart disease. The program may cover weight-loss medications in certain states, but they aren’t a mandatory benefit.
Losing weight after 60 can be a frustrating and challenging experience. Luckily, Medicare covers some other alternatives for managing weight loss. Medicare pays for:
Preventative care: Medicare covers cardiovascular and diabetes screenings if you’re at risk for these diseases.
Nutrition counseling: Medicare covers services from a nutrition expert if you have diabetes, chronic kidney disease, or had a kidney transplant in the last 36 months.
Weight-loss counseling: Medicare covers weight loss counseling if you have a BMI of 30 or higher. This includes regular screenings and meetings with a healthcare provider to set up plans for weight management plans.
Some obesity-related surgical procedures: Though there are strict eligibility requirements, Medicare covers gastric bypass surgery and laparoscopic banding surgery.
You’re not alone in your weight-loss journey. There are other ways Medicare can provide coverage for your weight management needs. Your plan may even cover more benefits around fitness and nutrition than you realize. Chapter is here to help you understand every aspect of your Medicare insurance and get the coverage you need for your health. Chat with a licensed Medicare Advisor for free and personalized information—call us at 855-900-2427 or schedule a time to talk today.
