Does Medicare Cover Ozempic?

(NerdWallet) – Ozempic, a drug used to treat type 2 diabetes, has gone viral as a weight-loss drug.

The hashtag #ozempic has over a billion views on TikTok, and more people search the web for Ozempic than insulin, Viagra or Tylenol, according to Google Trends data for May 2023.

Medicare beneficiaries interested in the drug may be surprised to see that it is often covered under Medicare Part D. It is one of the prescription drugs for which Medicare, the federal health care program for people age 65 and older and for young people with certain disabilities, spend the most money each year.

But Medicare doesn’t cover just diabetes. Nor does Medicare cover Wegovy, a weight-loss drug that uses the same active ingredient as Ozempic.

In fact, Medicare doesn’t cover any prescription weight-loss drugs. And due to legal barriers and cost concerns, that may not change anytime soon.

Here’s what to know about Medicare coverage of Ozempic and other weight-loss drugs.

What is Ozempic?

Ozempic is a brand name for semaglutide, a prescription drug manufactured and sold by Novo Nordisk. As an injection, it can help control blood sugar in people with type 2 diabetes.

The Food and Drug Administration approved Ozempic for the treatment of type 2 diabetes in December 2017. Currently, there is no generic version of the drug and there may not be for some time. Novo Nordisks’ Ozempic patents expire through December 2031, according to FDA data.

In June 2021, the FDA approved a semaglutide product for another purpose: weight loss. Novo Nordisk sells semaglutide for weight loss under the brand name Wegovy.

Medicare covers Ozempic for type 2 diabetes

Medicare prescription drug plans might cover Ozempic, but only to treat diabetes. In 2021, Medicare spent more than $2.6 billion covering Ozempic prescriptions. Because it is an outpatient prescription drug, Ozempic falls under Part D of Medicare. Original Medicare (Part A and/or Part B) will not cover it.

Ozempic is No. 10 for highest total Medicare Part D spending in 2021, according to data from the Centers for Medicare & Medicaid Services (CMS). About 459,000 Medicare beneficiaries were covered for Ozempic in 2021, according to CMS data.

If you have Original Medicare, you can purchase a standalone Medicare Part D plan to get prescription drug coverage. If you have Medicare Advantage, most plans include coverage for prescription drugs. You cannot purchase a separate Part D plan with Medicare Advantage.

You will need to check your plan form to confirm if and how your plan covers Ozempic.

Medicare doesn’t cover Ozempic (or Wegovy) for weight loss

More than 40 percent of U.S. adults ages 60 and older are considered obese, according to 2017-2020 data from the Centers for Disease Control and Prevention.

Despite the prevalence of obesity among the elderly, Medicare won’t cover weight-loss drugs, including Wegovy. Medicare Part D plans are prohibited from covering drugs used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (for example, morbid obesity)), according to the Medicare Prescription Drug Handbook Benefits.

This means that unless you have another source of coverage, you would have to pay out of pocket for a prescription for semaglutide for weight loss, whether it’s from Ozempic or Wegovy.

What would you pay out of pocket for Ozempic or Wegovy

The list price of Novo Nordisks for Ozempic is $935.77 for four weekly doses. For a full year, that would be nearly $12,200.

List price for Wegovy is $1,349.02 for four weekly doses. For a full year, that would be just over $17,500.

Since Ozempic and Wegovy are still under patent protection, there is no way to buy a cheaper generic version.

Weight-loss drug coverage would be expensive for Medicare

A policy change would be needed for Medicare to start covering weight-loss drugs. Legislation to allow coverage was introduced in each of the last six terms of Congress but never passed.

The high cost of weight-loss drugs could be a barrier to change. For example, if 10 percent of Medicare beneficiaries with obesity took Wegovy, Medicare Part D would cost about $26.8 billion annually, according to estimates published by researchers at Vanderbilt University School of Medicine and the University’s Department of Medicine. of Chicago in the New England Journal of Medicine in March 2023.

For reference, the prescription drug with the highest total Medicare Part D expense is Eliquis, an anti-stroke drug. Total Medicare Part D spending on Eliquis was nearly $12.6 billion in 2021, according to the most recent annual data available from CMS.

The estimated $26.8 billion to cover Wegovy would be more than double that amount, or about one-eighth of the approximately $216 billion spent on all drugs covered by Medicare Part D in 2021.

What does Medicare cover

Medicare covers many things but not everything. Find out where Medicare stands in the following areas: