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I take insulin for my diabetes, but I have heard from friends that Ozempic has helped them manage their diabetes and helps with weight loss, too.
I’m wondering, does Medicare cover Ozempic for Type 2 diabetes and weight loss?
Adeline from Houston, Texas
What a great question. Thanks for reaching out.
The Ozempic semaglutide medication tells the body to produce more insulin, reducing blood sugar levels or glucose. As an injection, Ozempic has been proven to lower the A1C in Type 2 diabetics. It can be prescribed in addition to your insulin or as a stand-alone medication.
So, you’re wondering if Medicare covers Ozempic? The short answer is no. Not Original Medicare.
Instead, most Medicare Prescription Drug plans, or Medicare Part D plans, include Ozempic in their formulary list. If you’re enrolled solely in Original Medicare, the only way to access Ozempic is to enroll in a Medicare Part D plan that includes the prescription on its formulary. Or if you have creditable prescription drug coverage from another source, like an employer, that includes this drug.
“Check the Medicare Part D or Medicare Advantage Prescription Drug plan’s formulary to ensure Ozempic is covered by the plan. It’s a tier-3 prescription and not every plan covers this tier. Also check if the drug’s co-pays are affordable before enrolling or switching plans.“
If you want access to Ozempic, check the Medicare Part D formulary before enrolling. Review the drug’s co-pays to ensure it’s within your budget – if covered under your Medicare Part D plan.
If enrolled in a Medicare Advantage Prescription Drug plan, you’d need to check that it includes Ozempic in its formulary. You may want to switch plans if it’s not in your current plan’s formulary. Because it’s a tier 3 prescription drug, most, but not every, plan includes Ozempic. It’s only available as a brand-name medication because Ozempic is under patent protection, and no cheaper generic option exists. If your Medicare Advantage plan offers coverage for Ozempic, ensure you can afford its co-pays before enrolling.
It’s unlikely that a generic version will be available soon. According to the Food and Drug Administration (FDA), Novo Nordisk’s Ozempic patent doesn’t expire until December 2031.
Even if you enroll in a Part D or a Medicare Advantage Prescription Drug plan that covers Ozempic, you must prove the prescription is medically necessary. And you made a great callout in your question. If you’re using Ozempic to manage your Type 2 diabetes, you’ll likely get coverage. If you want Ozempic for weight loss, you must pay for the drug out-of-pocket.
The FDA has not approved Ozempic as a weight loss medication. Instead, it controls diabetes, and weight loss has been a side effect.
Medicare prescription drug plans, including Part D and Medicare Advantage Prescription Drug plans, do not cover weight loss drugs. This includes medications for non-cosmetic purposes, such as morbid obesity, according to the Medicare Prescription Drug Benefit Manual.
This exclusion was enacted because of the dangers certain weight loss drugs, such as Fen-Phen, posed. Medicare does cover weight loss counseling and certain types of bariatric surgery for some people 65 and older who are obese.
You can only get weight-loss medications if you have creditable coverage from another source or pay out-of-pocket. In 2023, the monthly out-of-pocket cost for Ozempic is $935.77. The annual out-of-pocket cost is nearly $12,000.
This price includes pens of all strengths from 0.25 to 2 milligrams (mg). Your exact treatment cost will depend on your prescribed dose. You may start at a lower amount, such as 0.25 mg once a week for four weeks, then increase the dosage to 0.5 mg weekly. Depending on how this controls your blood sugar, your doctor may increase your dose to a maximum of 2 mg per week.
If you’re enrolling in Medicare for the first time and want Ozempic coverage, tell your local Connie Health agent. They can ensure that the Part D or Medicare Advantage Prescription Drug plan you enroll in includes the necessary medication coverage.
And if you’re looking to change to a plan that includes Ozempic, our licensed agents can help you navigate your plan choices. Whether you want to stay with Original Medicare or want a Medicare Advantage or Medicare Supplement plan to reduce out-of-pocket costs, we can help.
Speak with a local licensed agent today—call (623) 223-8884. We’re here to support you throughout your Medicare journey.
No, Medicare does not cover Ozempic for weight loss.
Medicare does not cover any medications for weight loss. This exclusion was made because of the dangers of specific weight loss drugs, such as Fen-Phen. This includes medications for non-cosmetic purposes such as morbid obesity.
No, Original Medicare Part A and B do not cover Ozempic.
However, you can get coverage under a Medicare Part D or Medicare Advantage Prescription Drug plan. Before choosing or switching to a new plan, check your prescription drug plan’s formulary to ensure Ozempic is included. Not all plans include Ozempic coverage because it is a tier 3 brand-name medication without a cheaper generic version. When checking your plan’s coverage, you should also review co-pays to ensure affordability.
Read more by Jasmine Alberto
I am a Spanish-speaking Texas Life and Health Insurance Licensed Agent and have been helping people with Medicare since 2007. I am on the the Advisory Committee for Foster Grandparents, Senior Companions, and RSVP Houston. I enjoy traveling, a backyard BBQ, and volunteering in my community.