Ozempic, a medication utilized in the treatment of Type 2 diabetes, has gained immense popularity as a weight loss drug. The #ozempic hashtag has garnered over a billion views on TikTok, and the number of people searching for Ozempic on the internet exceeds those searching for insulin, Viagra, or Tylenol, as per May 2023 data from Google Trends.
Interestingly, Medicare Part D often covers Ozempic, which may come as a surprise to beneficiaries. Medicare, the federal health care program for individuals aged 65 and older and those with specific disabilities, spends a substantial amount on Ozempic, making it one of the most costly prescription drugs each year.
However, it’s crucial to note that Medicare does not provide coverage for Ozempic as a weight loss treatment, only for diabetes. This also extends to Wegovy, a weight loss drug that shares the same active ingredient as Ozempic.
Furthermore, Medicare does not cover any prescription drugs intended for weight loss. Due to legal barriers and cost considerations, this situation is unlikely to change in the near future.
Now, let’s delve into the details of Medicare coverage for Ozempic and other weight loss medications.
An Introduction to Ozempic
Ozempic is the brand name for semaglutide, a prescription medication manufactured and sold by Novo Nordisk. This injectable medication helps regulate blood sugar levels in individuals with Type 2 diabetes.
The FDA endorsed Ozempic for the treatment of Type 2 diabetes in December 2017. Currently, there is no generic alternative available, and it may be several years before Novo Nordisk’s Ozempic patents expire, according to FDA data.
In June 2021, the FDA approved a semaglutide product for weight loss, which Novo Nordisk markets under the brand name Wegovy.
Medicare covers Ozempic for Type 2 diabetes
Medicare prescription drug plans may cover the cost of Ozempic, but only for the treatment of diabetes. In 2021, Medicare spent over $2.6 billion on Ozempic prescriptions. Since Ozempic is considered an outpatient prescription drug, it falls under Medicare Part D, while Original Medicare (Part A and/or Part B) does not cover it.
According to data from the Centers for Medicare & Medicaid Services (CMS), Ozempic ranked 10th in terms of highest Medicare Part D spending in 2021. CMS data indicates that approximately 459,000 Medicare beneficiaries received coverage for Ozempic in 2021.
If you have Original Medicare, you can purchase a stand-alone Medicare Part D plan to obtain prescription drug coverage. For those with Medicare Advantage, most plans include prescription drug coverage, and a separate Part D plan cannot be purchased.
It is essential to review your plan’s formulary to confirm the coverage details for Ozempic.
Medicare does not cover Ozempic (or Wegovy) for weight loss
Over 40% of adults aged 60 and older in the United States are classified as obese, based on data from 2017-2020 collected by the Centers for Disease Control and Prevention.
Despite the prevalence of obesity among older adults, Medicare does not provide coverage for weight loss drugs, including Wegovy. According to the Medicare Prescription Drug Benefit Manual, Medicare Part D plans are explicitly prohibited from covering drugs intended for anorexia, weight loss, or weight gain, even for non-cosmetic purposes such as morbid obesity.
Therefore, unless you have an alternative source of coverage, you would need to pay for a prescription of semaglutide for weight loss, whether it is Ozempic or Wegovy.
Out-of-pocket Costs for Ozempic or Wegovy
The list price for a four-week supply of Ozempic is $935.77. Therefore, the total cost for a year’s supply would come to nearly $12,200.
On the other hand, Wegovy is priced at $1,349.02 for a four-week dose, amounting to slightly over $17,500 for a year’s supply.
As both Ozempic and Wegovy are still protected by patents, there are currently no cheaper generic options available.
The Cost Implications of Covering Weight Loss Drugs for Medicare
A change in policy would be necessary for Medicare to begin covering weight loss drugs. Although legislation advocating for coverage has been introduced in each of the last six congressional terms, it has never been passed.
One potential barrier to change is the high cost associated with weight loss drugs. If 10% of Medicare beneficiaries with obesity opted for Wegovy, it would cost Medicare Part D approximately $26.8 billion annually, as estimated by researchers at Vanderbilt University School of Medicine and the University of Chicago Department of Medicine, as published in the New England Journal of Medicine in March 2023.
For comparison, the prescription drug with the highest total Medicare Part D spending in 2021 was Eliquis, an anti-stroke medication, which amounted to nearly $12.6 billion, as per the most recent annual data from CMS.
The estimated cost of $26.8 billion required to cover Wegovy would be more than double that amount, representing approximately one-eighth of the total expenditure for all covered Medicare Part D drugs in 2021, which was approximately $216 billion.
More From NerdWallet
Alex Rosenberg writes for NerdWallet. Email: [email protected]. Twitter: @AlexPRosenberg.
Denial of responsibility! VigourTimes is an automatic aggregator of Global media. In each content, the hyperlink to the primary source is specified. All trademarks belong to their rightful owners, and all materials to their authors. For any complaint, please reach us at – [email protected]. We will take necessary action within 24 hours.
