Is Wegovy Covered by Medicare: Your Guide to Coverage
Wegovy, a popular weight loss drug, has helped many people manage obesity. But is Wegovy covered by Medicare? This article explains Medicare’s coverage for Wegovy in simple terms.
We’ll cover recent updates, costs, and what you need to know to access this medication.
What Is Wegovy?
Wegovy is a brand-name drug with the active ingredient semaglutide. It’s a GLP-1 receptor agonist, taken as a weekly injection. Approved for weight loss in adults and teens with obesity, it also reduces heart disease risk. Wegovy works by curbing appetite and slowing digestion.
The drug is prescribed for people with a body mass index (BMI) of 30 or higher. It’s also used for those with a BMI of 27 or more with weight-related conditions like diabetes. Medicare coverage depends on how Wegovy is prescribed. Let’s explore the details.
Medicare’s Rules for Weight Loss Drugs
Medicare is a federal health insurance program for people 65 and older or with certain disabilities. It includes Part D for prescription drugs and Part B for doctor-administered treatments. A 2003 law bans Medicare from covering drugs used only for weight loss. This rule affects Wegovy when prescribed solely for obesity.
However, Medicare can cover drugs for other medical conditions. If Wegovy is prescribed for a non-weight-loss purpose, coverage is possible. Recent changes have expanded when Medicare covers Wegovy. These updates focus on heart health benefits.
Recent Updates on Wegovy Coverage
In March 2024, the FDA approved Wegovy to reduce heart attack and stroke risk. This applies to adults with cardiovascular disease and obesity or overweight. This new use allows Medicare Part D plans to cover Wegovy for eligible patients. The Centers for Medicare & Medicaid Services (CMS) issued guidance to support this change.
About 3.6 million Medicare beneficiaries may qualify for this coverage. This is roughly 7% of all Medicare enrollees, based on 2020 data. Coverage is limited to those with heart disease and obesity or overweight. Weight loss alone still isn’t covered.
How Medicare Part D Covers Wegovy
Medicare Part D plans, offered by private insurers, cover self-administered drugs like Wegovy. Since Wegovy is a weekly injection you take at home, it falls under Part D, not Part B. Plans can now include Wegovy for heart disease prevention. However, not all Part D plans automatically cover it.
Each plan has a formulary, or list of covered drugs. You’ll need to check your plan’s formulary to confirm Wegovy is included. Some plans may require prior authorization or step therapy. This means trying other treatments first.
Who Qualifies for Wegovy Coverage?
To qualify for Medicare coverage of Wegovy, you must meet specific criteria. You need a diagnosis of cardiovascular disease, such as a prior heart attack or stroke. You must also have obesity (BMI of 30 or higher) or be overweight (BMI of 27 or higher). A Medicare-approved doctor must prescribe Wegovy for heart disease prevention.
If you’re taking Wegovy only for weight loss, Medicare won’t cover it. About 1.9 million of the eligible 3.6 million beneficiaries also have diabetes. These individuals may already qualify for other GLP-1 drugs like Ozempic.
Costs of Wegovy with Medicare
Wegovy’s list price is around $1,349 per month without insurance. With Medicare Part D, costs vary based on your plan’s structure. You may face a deductible, copayments, or coinsurance of 25% to 33%. This could mean $325 to $430 monthly before hitting out-of-pocket limits.
In 2024, Medicare caps out-of-pocket drug costs at $3,300 for brand-name drugs. This drops to $2,000 in 2025, thanks to the Inflation Reduction Act. These caps help limit expenses, but costs can still be high for some.
Table: Estimated Wegovy Costs with Medicare Part D
| Cost Type | Details | Estimated Amount |
|---|---|---|
| Monthly List Price | Before discounts or coverage | $1,349 |
| Coinsurance | 25%–33% of list price | $325–$430/month |
| 2024 Out-of-Pocket Cap | Maximum drug costs per year | $3,300 |
| 2025 Out-of-Pocket Cap | Maximum drug costs per year | $2,000 |
This table shows potential costs for Wegovy under Medicare Part D. Check your plan for exact amounts.
Medicare Advantage Plans and Wegovy
Medicare Advantage (Part C) plans are private alternatives to Original Medicare. Most include Part D drug coverage, and some may cover Wegovy for heart disease prevention. However, coverage varies widely by plan. You’ll need to contact your plan administrator to confirm.
Some Advantage plans use prior authorization or place Wegovy on a specialty tier. Specialty tiers often mean higher copays or coinsurance. Reviewing your plan’s formulary is essential. Not all Advantage plans cover Wegovy, even for heart disease.
Why Medicare Doesn’t Cover Weight Loss
The 2003 Medicare Modernization Act labels weight loss drugs as “cosmetic.” This prevents coverage for drugs like Wegovy when used only for obesity. Lawmakers viewed weight loss as non-essential at the time. This rule remains in effect despite obesity’s health risks.
Efforts to change this law, like the Treat and Reduce Obesity Act, have been proposed. These aim to allow Medicare to cover anti-obesity drugs. Until laws change, coverage is limited to non-weight-loss uses. Heart disease prevention is the main pathway now.
Other GLP-1 Drugs and Medicare
Wegovy isn’t the only GLP-1 drug. Ozempic, also semaglutide, is covered by Medicare for type 2 diabetes. Mounjaro, with tirzepatide, is similarly covered for diabetes but not weight loss. These drugs work like Wegovy but have different approved uses. Coverage depends on the diagnosis.
If you have diabetes, you may qualify for Ozempic or Mounjaro under Part D. This could be an alternative if Wegovy isn’t covered for you. Discuss options with your doctor. They can prescribe based on your health needs.
How to Check Wegovy Coverage
To find out if your plan covers Wegovy, start with your Part D or Advantage plan’s formulary. This list is available online or through your plan’s customer service. Look for Wegovy under specialty or tiered drugs. Note any requirements like prior authorization.
You can also call Medicare at 1-800-MEDICARE for help. Your doctor or pharmacist can assist in verifying coverage. If Wegovy isn’t covered, ask about appeals or alternative drugs. Being proactive ensures you understand your options.
Steps to Get Wegovy Covered
If you think you qualify, follow these steps to access coverage. First, get a diagnosis of cardiovascular disease and obesity or overweight. Your doctor must document this and prescribe Wegovy for heart disease prevention. Submit the prescription to your Part D plan.
If denied, you can appeal the decision. Medicare allows appeals for coverage disputes. Your doctor can provide supporting documents. Patience is key, as approvals may take time.
Tips to Navigate Wegovy Coverage
- Check your plan’s formulary for Wegovy.
- Confirm your diagnosis with a Medicare-approved doctor.
- Ask about prior authorization or step therapy.
- Use Medicare’s website to compare plans.
These steps help you secure coverage and manage costs.
Financial Help for Wegovy
If Medicare doesn’t cover Wegovy, or costs are too high, other options exist. Novo Nordisk, Wegovy’s maker, offers a savings card for cash-paying patients. This can lower costs to $499 per month for some. Check NovoCare.com for eligibility.
Patient assistance programs or discount coupons may also help. If you lack Part D coverage, explore state Medicaid or private insurance. Discuss affordability with your doctor to find solutions.
Potential Challenges with Coverage
Not all Part D plans cover Wegovy, even for heart disease. Some may delay adding it to formularies until 2025. Prior authorization or step therapy can slow access. High coinsurance can also be a barrier, especially for those on fixed incomes.
Appeals or switching plans during open enrollment (October 15–December 7) may help. Compare plans on Medicare.gov to find one covering Wegovy. Work closely with your doctor to meet plan requirements.
Future of Wegovy Coverage
The Biden administration proposed expanding Medicare and Medicaid coverage for weight loss drugs in November 2024. This would recognize obesity as a treatable disease. However, the incoming Trump administration may block this rule. Robert F. Kennedy Jr., a Trump nominee, opposes covering these drugs.
If passed, the rule could cover Wegovy for obesity, benefiting millions. For now, coverage remains limited to heart disease. Stay informed about policy changes through Medicare or news updates.
Summary
Is Wegovy covered by Medicare? Yes, but only for adults with cardiovascular disease and obesity or overweight, following a 2024 FDA approval. Medicare Part D plans may cover Wegovy for heart disease prevention, not weight loss.
About 3.6 million beneficiaries may qualify, but costs like $325–$430 monthly coinsurance can apply. Coverage varies by plan, and prior authorization may be required.
Check your Part D or Advantage plan’s formulary to confirm coverage. If denied, appeals or alternative drugs like Ozempic may help. Savings programs and future policy changes could improve access. Work with your doctor to navigate costs and requirements.
FAQ
Is Wegovy covered by Medicare for weight loss?
No, Medicare doesn’t cover Wegovy for weight loss due to a 2003 law. It’s covered only for heart disease prevention in those with obesity or overweight. Check your Part D plan for details.
How much does Wegovy cost with Medicare?
With Part D, you may pay $325–$430 monthly in coinsurance (25%–33%). Out-of-pocket costs are capped at $3,300 in 2024 and $2,000 in 2025. Costs vary by plan.
Who qualifies for Wegovy under Medicare?
You need cardiovascular disease and obesity (BMI 30+) or overweight (BMI 27+). A doctor must prescribe it for heart disease prevention. About 3.6 million beneficiaries may qualify.
Does Medicare Advantage cover Wegovy?
Some Advantage plans with Part D coverage include Wegovy for heart disease. Coverage varies, so check your plan’s formulary. Prior authorization or specialty tiers may apply.
What if my plan doesn’t cover Wegovy?
Appeal the denial with your doctor’s help or explore savings cards from Novo Nordisk. Consider switching plans during open enrollment. Alternative drugs like Ozempic may be covered.
