GLP-1 drugs like Wegovy, Ozempic, Trulicity, and more are generating a lot of buzz for their effectiveness in weight loss and diabetes management. But for Medicare beneficiaries, understanding coverage for these medications can feel like deciphering a complex puzzle. Let’s break down what you need to know about Wegovy and Ozempic and how Medicare fits into the picture.
Wegovy, Ozempic, Mounjaro, and Trulicity are brand names for GLP-1 (glucagon-like peptide-1) agonists or semaglutide, a drug that mimics a natural hormone to help control blood sugar and appetite. The key difference is their approved uses.
For example, Wegovy is specifically approved for chronic weight management in adults who are overweight. Recently though, Wegovy was approved for reducing the risk of heart attacks and strokes, and Ozempic is approved for treating type 2 diabetes. As medical research continues, these drugs may be approved to treat more conditions.
Medicare is legally prohibited from covering weight loss medications. However, it can cover medications for other approved medical uses like diabetes and heart disease. These drugs would be covered under Medicare Part D or Medicare Advantage (MA) plans, not Medicare Part B because it’s a self-administered medication. And Medicare Part D and MA plans cover Ozempic for type 2 diabetes treatment, but your doctor must prescribe it specifically for that to be eligible.
On the other hand, Wegovy’s recent FDA approval for reducing the risk of heart attack, stroke, or death in adults with overweight or obesity and cardiovascular disease has opened the door for Medicare coverage. This is significant because, based on 2020 data, this approved use could make approximately 3.6 million Medicare beneficiaries eligible for Wegovy coverage.
However, navigating coverage for GLP-1 drugs is not without its challenges. Firstly, the drugs come with a hefty list price, especially in the U.S. As of this writing, Wegovy is listed at $1,300 per month. Even with Part D or MA coverage, you could face substantial out-of-pocket costs. Coinsurance may require you to pay 25-33% of the drug cost, which could amount to $325-$430 per month (according to the list price above). While the new out-of-pocket maximums in 2024 and 2025 offer some relief, even the $2,000 limit can still pose a financial burden for many beneficiaries.
Furthermore, some Medicare plans may require prior authorization for these kinds of drugs, potentially leading to delays or even denial of coverage. Note: How much beneficiaries pay out of pocket will depend on the plan and insurer as Part D and MA plans are managed by private insurers.
If you’re considering Wegovy or Ozempic, it’s crucial to be proactive. Talk to your doctor to determine if these medications are right for you and if you meet the criteria for Medicare coverage. Contact your prescription plan provider to confirm their formulary status and understand your potential out-of-pocket costs. Don’t hesitate to explore assistance programs, such as manufacturer discounts or patient assistance programs, that could help make these treatments more affordable.
The landscape of Medicare coverage for GLP-1 medications is constantly evolving. Stay informed about the latest changes and advocate for affordable access to these potentially life-changing treatments.
*Disclaimer:
The information provided in this blog post is intended for general informational purposes only and does not constitute medical advice. It is not a substitute for professional medical consultation or treatment. Always consult with a qualified healthcare provider for any questions you may have regarding a medical condition.
SmartMatch does not endorse or recommend any specific products, treatments, or procedures mentioned in this article. Reliance on any information provided in this blog post is solely at your own risk. We encourage you to discuss any health concerns or questions with your doctor before making any decisions about your health or treatment.
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