How Medicare Covers Ozempic for Weight Loss
Finding effective solutions to manage weight loss can sometimes feel like searching for a needle in a haystack. But what if there was a medication that could help you on your journey? Enter Ozempic, a breakthrough drug making waves in the weight loss community. Does Medicare cover Ozempic for weight loss?
In this article, we will explore how Medicare may give you access to Ozempic, giving you the insights you need to make informed health decisions. We’ll also explore the eligibility criteria, coverage options, and potential costs. Whether you’re already enrolled in Medicare or considering it in the future, this information is invaluable for those seeking weight management solutions.
What is Ozempic?
Ozempic is a medication used to treat type 2 diabetes in the class of drugs called GLP-1 receptor agonists. As a GLP-1 receptor agonist, semaglutide enhances the effects of the naturally occurring hormone GLP-1, which helps lower blood sugar levels. This medication is administered once weekly via injection, making it a convenient option for those managing diabetes. Ozempic is effective in reducing A1C levels and promoting weight loss in patients.
A 0.25 or 0.5-milligram dose of Ozempic currently retails on the Novo Nordisk website for $935.77 without insurance. However, those with private or commercial insurance who are eligible for a prescription may pay as little as $25. Medicare Part D and Part D copays for Ozempic can be significantly higher, especially if you fall into the Gap (or Donut Hole).
How Does Ozempic Work?
Ozempic works by mimicking the action of a naturally occurring hormone called glucagon-like peptide-1 (GLP-1) in the body. GLP-1 helps regulate blood sugar levels by stimulating insulin release, slowing down digestion, and reducing appetite. By activating GLP-1 receptors, Ozempic helps lower blood sugar levels, decrease appetite, and promote weight loss.
Who Can Benefit from Ozempic?
Ozempic is primarily prescribed to individuals with type 2 diabetes who have not achieved adequate glycemic control through lifestyle changes, such as diet and exercise, or oral diabetes medications alone. It is typically used as an adjunct to diet and exercise to improve blood sugar control.
GLP-1 also impacts weight via two key mechanisms:
- Affects the hunger centers in the brain (specifically, in the hypothalamus), reducing hunger, appetite, and cravings
- Slows the rate of stomach emptying, effectively prolonging fullness and satiety after meals
The net result is decreased hunger, prolonged fullness, and, ultimately, weight loss.
The Benefits of Ozempic for Weight Loss
Ozempic has gained significant attention in the weight loss community due to its potential benefits. Studies have shown that Ozempic can lead to significant weight loss when used with a healthy diet and exercise. In fact, clinical trials have demonstrated that individuals using Ozempic experienced an average weight loss of 5-10% of their body weight over a 26-52 week period. This is a remarkable achievement, considering many individuals’ challenges when trying to lose weight.
In one large clinical trial sponsored by Novo Nordisk, 1,961 adults with excess weight or obesity who did not have diabetes were given 2.4 milligrams of semaglutide or a placebo once a week for 68 weeks, along with lifestyle intervention. Those who took semaglutide lost 14.9% of their body weight compared with 2.4% for those who took the placebo.
Understanding Medicare Coverage
Before we dive into the specifics of Medicare coverage for Ozempic, it’s important to have a basic understanding of how Medicare works.
Medicare is a federal health insurance program primarily designed for individuals aged 65 and older, as well as certain younger individuals with disabilities. It consists of different parts, including Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).
Medicare covers a wide range of medical services and treatments, including prescription medications. However, coverage for prescription drugs can vary depending on the specific plan you have. Some plans may cover a broader range of medications, while others may have more limited coverage. Understanding your specific Medicare plan is essential to determining the coverage options available for Ozempic.
How Medicare Covers Ozempic for Weight Loss
To determine if Ozempic is covered by Medicare for weight loss, you need to check whether it is included in your Medicare Part D plan’s formulary. A formulary is a list of prescription drugs covered by a specific Medicare plan. You can typically find this information in the plan’s drug formulary document, which is usually available on the plan’s website or by contacting customer service.
All 21 Medicare Part D prescription drug plans and all 30 Medicare Advantage plans cover Ozempic in the Omaha, Lincoln, and Council Bluffs areas. Depending on the plan, you may or may not have a drug deductible and then copays. Ozempic is usually a tier 3 medication with a hefty copay. Depending on your total medications, you may or may not go into the Gap (or Donut Hole).
If Ozempic is included in the formulary, it means that it is covered by your Medicare Part D or Part C plan. However, coverage may still be subject to certain conditions. The medication must be medically necessary for the prescribed purpose. Other factors include prior authorization or step therapy.
Prior authorization requires your healthcare provider to obtain approval from the Part D prescription drug plan before prescribing Ozempic, while step therapy may require you to try other medications before Ozempic is covered.
Review the specific coverage requirements outlined in your Medicare Part D plan to ensure you meet all the necessary criteria for Ozempic coverage. It is important to understand Medicare covers Ozempic for diabetic and pre-diabetic treatment. Medicare does not cover Ozempic for weight loss exclusively.
Why Medicare Does Not Cover Ozempic for Weight Loss
Medicare Part D prescription drug plans were created under the Busch Administration. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 determined that Part D prescriptions could not cover medications for cosmetic or weight loss reasons. Thus, Ozempic is only covered by Medicare for type 2 diabetes. Ozempic is not covered by Medicare for weight loss.
Wegovy: An Alternative?
Wegovy is a brand-name version of the drug semaglutide, which is the medication Ozempic in a different dosage. The FDA approves Wegovy as a chronic weight management medication, not for type 2 diabetes, like Ozempic.
Medicare, however, does not cover Wegovy because the drug is for weight loss. Medicare does not cover weight loss medications even though obesity is intimately tied to diabetes and a cause of poor health.
How to Navigate the Medicare Coverage Process for Ozempic
Here are some suggestions for you to navigate the Medicare coverage process for Ozempic.
Check the Formulary
Look for Ozempic in your plan’s formulary to determine if it is covered. Note any additional coverage requirements, such as prior authorization or step therapy.
Consult Your Healthcare Provider
Diabetes and pre-diabetes are usually related to obesity. Discuss your diabetes or pre-diabetes in relation to your weight loss goals with your healthcare provider. See if Ozempic is a suitable option for you. They can help guide you through the coverage process and provide any necessary documentation.
Prior Authorization or Step Therapy
If your plan requires prior authorization or step therapy for Ozempic, work with your healthcare provider to complete the necessary paperwork and submit it to Medicare for approval.
Those who are type 2 diabetic or pre-diabetic AND overweight may be able to get access to Ozempic for their healthcare needs, which secondarily includes weight loss.
Dangers of Ozempic
Ozempic, however, isn’t safe for everyone. According to the company, people with the following conditions should avoid using Ozempic:
- Pancreatitis
- Type 1 diabetes
- Under 18 years of age
- Pregnant or breastfeeding
- Diabetic retinopathy
- Problems with the pancreas or kidneys
- Family history of medullary thyroid carcinoma (MTC)
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), an endocrine system condition
As with any prescription medication, you must consult your doctor or other qualified healthcare provider on whether this medication is safe for you and what dosage is appropriate.
Ozempic Side Effects and Health Risks
There are many side effects of taking Ozempic as a weight loss medication, including
- Gastrointestinal issues like nausea, vomiting, and diarrhea
- Constipation
- Stomach pain
- Headache
- Excessive burping
- Heartburn
- Fatigue
- Flatulence
- Gastroesophageal reflux disease
These most common side effects of Ozempic don’t tend to be dangerous and may dissipate as you grow used to the medication. However, there is potential for more serious adverse effects, such as:
- Vision problems
- Swelling in extremities
- Dizziness or fainting
- Reduced urination
- Rash
- Rapid heart rate
- Swelling of throat, tongue, mouth, face, or eyes
- Problems swallowing or breathing
- Fever
- Yellow eyes or skin
- Chronic upper stomach pain
Wegovy, another brand name for semaglutide, may also cause damage to the retina, suicidal ideation, gallstones, pancreatitis, and acute kidney damage.
Moreover, taking semaglutide can increase the chance of developing thyroid tumors, including medullary thyroid carcinoma. Speak with your doctor if you are experiencing any of the side effects listed above.
“Ozempic Face”
You may have heard about “Ozempic face” as a side effect of GLP-1 drugs, though the term is misleading because this can be a side effect of any GLP-1 drug or any other cause of rapid weight loss.
The rapid loss of fat in the face can cause:
- a hollowed look to the face
- changes in the size of the lips, cheeks, and chin
- wrinkles on the face
- sunken eyes
- sagging jowls around the jaw and neck.
If weight is lost more gradually, these changes may not be as noticeable. However, the faster pace of weight loss that occurs with GLP-1 drugs can make facial changes more obvious.
Spending for the three GLP-1 medications, Ozempic, Rybelsus, and Mounjaro, has skyrocketed in the past year on Medicare. While more Medicare beneficiaries are becoming diabetic and using these medications, the number far exceed that type of increase. A significant portion of people on Medicare are now using GLP-1 medications for weight loss.
Medicare Spending on Ozempic Explodes
Impact on Diabetes Patients
The popularity of Ozempic’s off-label use for weight loss is driving a global shortage of diabetes drugs. Pharmacies in the U.S., Canada, and Europe have been reporting shortages. My clients have reported to me their experience of not finding Ozempic at their local pharmacy.
If the shortages persist, people who’ve relied on Ozempic to treat their diabetes may face difficulty adjusting to alternatives. The shortage of Ozempic, driven by its off-label use for weight loss, can have significant consequences for patients with diabetes who genuinely need the medication.
Bottom Line: Medicare Does Not Cover Ozempic for Weight Loss
Ozempic is a dilemma. Most diabetics are overweight, but not all overweight persons are diabetic or pre-diabetic. Medicare does not cover Ozempic for weight loss, but it does cover it for diabetes or pre-diabetes. Weight loss is usually an important element in minimizing the negative effects of diabetes.
While Medicare does not cover Ozempic for weight loss, strictly speaking, Medicare does cover Ozempic for a very large population that also needs and will benefit from Ozempic and losing weight. People aren’t stupid.
It’s actually not a bad solution for an imperfect and overweight world.
