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Health Insurance
Medicare
MEDICARE COVERAGE FOR OFF-LABEL OZEMPIC TO LOSE WEIGHT
By Tanya Feke, MD
Updated on January 16, 2024
Medically reviewed by Kelly Wood, MD
Fact checked by Nick Blackmer
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Table of Contents
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Table of Contents
* When Covered
* When Not Covered
* Getting It Covered
* Other Savings
Semaglutide (brand name Ozempic) is a medication that was first developed to
treat type 2 diabetes. While it was effective in controlling blood sugar, it was
also found to decrease appetite and promote weight loss. One study found that
people lost as much as 6% of their weight within three months and up to 11% in
six months of taking it.1
Unfortunately, Medicare covers this medication only in certain situations. For
example, Ozempic is covered for the treatment of type 2 diabetes; it is not
covered for the purpose of weight loss.
This article will discuss the conditions for which Medicare covers Ozempic, when
it does not, and how to get savings on Ozempic if not covered by your health
insurance.
imyskin / Getty Images
WHEN DOES MEDICARE COVER OZEMPIC?
Medicare covers medications that it considers to be medically necessary. This
includes most drugs approved by the Food and Drug Administration (FDA) for
certain indications, which include a diagnosis, illness, injury, syndrome, or
condition.
Ozempic is an injectable medication in the class of drugs known as glucagon-like
peptide agonists (GLP-1 medications). It has an FDA-approved indication for type
2 diabetes and for cardiovascular-event reduction in people who have both type 2
diabetes (the body cannot properly regulate and use blood sugar as fuel) and
known cardiovascular disease (conditions affecting the heart and blood vessels).
Many Medicare Part D plans will cover Ozempic for beneficiaries who have these
conditions.
OFF-LABEL USE
In some cases, medications are used off-label. This means a healthcare provider
prescribes a medication for a different medical indication than approved by the
FDA, or at a different dose, frequency, or administration.
The Centers for Medicare and Medicaid Services (CMS) may allow coverage for
medications for off-label use if that treatment is accepted as reasonable care,
if it has medical research to back it up, and if it is accepted as a standard of
practice in the medical community.2
Having obesity can increase your risk for a number of medical conditions,
including heart disease, diabetes, and sleep apnea (breathing repeatedly stops
and starts while sleeping), among others.3 For some people, lifestyle
modifications like diet and exercise are not always enough to decrease those
risks. That is why many people turn to medications like semaglutide to help with
weight loss.
OBESITY DEFINITION AND STATISTICS
Obesity is a medical condition defined by excess fat in the body. According to
the Centers for Disease Control and Prevention (CDC), almost 42% of adults in
the United States have obesity.4 "Obesity" is medically defined as a body mass
index (BMI) greater than 30.
BMI is a calculation based on weight and height. It is considered a flawed
measurement since it does not take into consideration many other factors
affecting body mass.
REASONS MEDICARE WON’T COVER OZEMPIC
When the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of
2003 created Medicare Part D, it included a rule that medications could not be
covered for cosmetic reasons or for the purposes of weight loss.5 This,
unfortunately, limits how Ozempic is covered, and if you do not have type 2
diabetes, Medicare Part D will not cover it.
WHAT ABOUT WEGOVY?
Like Ozempic, Wegovy is brand-name version of the drug semaglutide. Unlike
Ozempic, its FDA indication is not for type 2 diabetes but for chronic weight
management. Because the drug is for weight loss, Medicare does not cover it.
Incidentally, the MMA was passed before the American Medical Association (AMA)
designated obesity as a disease in 2013.6
With rising rates of obesity and obesity-related complications, the AMA in 2023
argued for coverage of obesity treatment. It stated, “The AMA will urge health
insurers to provide coverage of available FDA-approved weight-loss medications,
including GLP-1 medications, to demonstrate a commitment to the health and
well-being of our patients.”7
A 2023 analysis by the Leonard D. Schaeffer Center for Health Policy & Economics
at the University of Southern California (USC) looked at the potential effects
drugs like this could have on the healthcare system. They estimated that
Medicare could save as much as $245 billion over 10 years if it expanded
coverage to include weight loss treatments.5
Although there is an upfront cost to using these medications, treatment targeted
to weight loss would decrease obesity-related complications, treatments for
those conditions, and the need for hospitalization. With more potential savings
than spending, it is possible that Medicare could reconsider the decision to
cover weight loss medications in the future.
HOW TO GET MEDICARE TO PICK UP OZEMPIC COST
As a brand-name drug, Ozempic can be quite expensive. Novo Nordisk, the
pharmaceutical company that makes the drug, notes that each Ozempic
auto-injector pen costs a retail price of $937.8 Depending on the dose you take,
you may have to pay more or less than this amount each month.
If you are fortunate enough to have insurance, your out-of-pocket costs could be
much lower. This assumes your healthcare plan covers the drug.
Because the GLP-1 class of medications is more expensive than many other classes
of antidiabetic drugs, your Part D plan may require your healthcare provider to
verify why Ozempic is medically necessary for you before it will cover the drug.
This is known as prior authorization.
Your plan may also require you to try other lower-cost medications first as a
way to keep costs down. This is known as step therapy.
Speak with your healthcare provider to make sure that they have all the
information needed for Medicare to cover Ozempic. A diagnosis of type 2 diabetes
is essential, but a BMI calculation should be included in any documentation to
your Part D plan to improve your odds of coverage.
OTHER WAYS TO GET SAVINGS ON OZEMPIC
Novo Nordisk offers a savings card that can reduce the cost of Ozempic to as
little as $25 per month.9 To take advantage of this program, you must have
commercial insurance, and you cannot be on Medicare or Medicaid.
Because there are no savings opportunities for people who do not have insurance
or for people using federal programs, equal access for all is not possible.
If you are on Medicare, you should determine if you qualify for the Part D Low
Income Subsidy, referred to as Extra Help.10 This can decrease how much you pay
for your medications in deductibles, coinsurance, or co-pays during the year.
Thanks to the Inflation Reduction Act, more people will be eligible for the
subsidy program in 2024.
All formulations of semaglutide, including the following, promote weight loss,
not just Ozempic:
* Wegovy: It is an injectable version of semaglutide, but the medication comes
in different doses than Ozempic. Because the drug is FDA-approved for weight
loss, it is not covered by Medicare, but you may be able to acquire discounts
through the manufacturer.11
* Rybelsus: This brand of semaglutide is taken by mouth, not injection. With an
FDA-approved indication for diabetes, it may be covered by your Medicare Part
D plan. The amount of predicted weight loss is comparable to the injectable
versions.12 Discounts are also available through Novo Nordisk for people who
have commercial insurance but not for those on Medicare or Medicaid.11
GLP-1 MEDICATIONS
Other GLP-1 medications can also promote weight loss. Mounjaro (tirzepatide) is
one such medication. With an FDA-approved indication for type 2 diabetes,
Medicare Part D may cover it. Its manufacturer, Eli Lilly, reports a list price
of $1,069 per month. Like Ozempic, discount cards are available for people who
are insured but not for those who are on Medicare or Medicaid.13
SUMMARY
Ozempic and other GLP-1 medications are effective weight loss medications that
may or may not be covered by Medicare Part D. Because current legislation does
not allow Medicare Part D to cover weight loss medications, these drugs will
only be covered when they are used to treat diabetes.
That could change as professional organizations lobby for coverage of
weight-loss medications by Medicare in the future.
13 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies,
to support the facts within our articles. Read our editorial process to learn
more about how we fact-check and keep our content accurate, reliable, and
trustworthy.
1. Ghusn W, De la Rosa A, Sacoto D, et al. Weight loss outcomes associated
with semaglutide treatment for patients with overweight or obesity. JAMA
Netw Open. 2022;5(9):e2231982. doi:10.1001/jamanetworkopen.2022.31982
2. Centers for Medicare & Medicaid Services. Local coverage determination:
drugs and biologicals, coverage of, for label and off-label uses.
3. Centers for Disease Control and Prevention. Health effects of overweight
and obesity.
4. Stierman B, Afful J, Carroll MD, et al. National Health and Nutrition
Examination Survey 2017–March 2020 prepandemic data files—development of
files and prevalence estimates for selected health outcomes. Natl Health
Stat Report. 2021;158. doi:10.15620/cdc:106273
5. University of Southern California, Leonard D. Schaeffer Center for Health
Policy & Economics. Benefits of Medicare coverage for weight loss drugs.
6. Luli M, Yeo G, Farrell E, et al. The implications of defining obesity as a
disease: a report from the Association for the Study of Obesity 2021 annual
conference. EClinicalMedicine. 2023;58:101962-101962.
doi:10.1016/j.eclinm.2023.101962
7. American Medical Association. AMA urges insurance coverage parity for
emerging obesity treatment options.
8. Novocare. Find out the cost of Ozempic.
9. Novocare. Ozempic (semaglutide) injection 0.5mg, 1 mg, or 2 mg savings
offer.
10. Social Security Administration. Apply for Medicare Part D Extra Help
program.
11. Novocare. Diabetes savings card program.
12. Novo Nordisk. Oral semaglutide 50 mg achieved 15.1% weight loss (17.4% if
all people adhered to treatment) in adults with obesity or overweight in
the OASIS 1 trial.
13. Eli Lilly. Mounjaro cost information.
By Tanya Feke, MD
Tanya Feke, MD, is a board-certified family physician, patient advocate and
best-selling author of "Medicare Essentials: A Physician Insider Explains the
Fine Print."
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