Does Medicare Cover Ozempic for Diabetes?

Does Medicare Cover Ozempic? Ozempic, a pharmaceutical agent employed in the management of Type 2 diabetes, has garnered considerable interest in its potential as a therapeutic intervention for weight loss. With the #ozempic hashtag amassing over a billion views on TikTok, it’s clear that many people are curious about the drug’s effects.

However, Medicare beneficiaries might be surprised to learn that while Medicare Part D often covers Ozempic, it does so exclusively for diabetes treatment, not weight loss. 

Medicare does not cover any prescription drugs for weight loss, including Ozempic and its weight loss counterpart, Wegovy. 

This article discusses Medicare coverage for Ozempic and other weight reduction medicines, including the reasons for the restriction and the costs.

What is Ozempic?

Ozempic, a brand name for the prescription medication semaglutide, is manufactured and sold by Novo Nordisk. This injectable medicine helps Type 2 diabetics regulate blood sugar. Ozempic, FDA-approved in December 2017, has no generic form. 

According to FDA data, Novo Nordisk’s patents for Ozempic are set to expire as late as December 2031. It’s worth noting that in June 2021, the FDA approved semaglutide for another purpose: weight loss. Under the brand name Wegovy, Novo Nordisk offers semaglutide specifically for weight loss.

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Does Medicare Cover Ozempic for Type 2 Diabetes?

Medicare prescription drug plans, specifically Medicare Part D, may cover Ozempic for the treatment of Type 2 diabetes. In 2021 alone, Medicare spent over $2.6 billion to cover Ozempic prescriptions. As an outpatient prescription drug, Ozempic falls under the coverage of Medicare Part D. 

It’s important to note that Original Medicare (Part A and/or Part B) does not cover Ozempic. Individuals with Original Medicare can purchase a stand-alone Medicare Part D plan to access prescription drug coverage through Medicare.

On the other hand, Medicare Advantage plans, which combine Part A, Part B, and sometimes Part D coverage, usually include prescription drug coverage. 

Beneficiaries need to review their plan’s formulary, which outlines the specific drugs covered and any associated costs, to confirm Ozempic coverage.

Does Medicare Cover Ozempic for Diabetes?Pin
Does Medicare Cover Ozempic for Diabetes?

Ozempic and Wegovy Exclusively Covered for Diabetes, Not Weight Loss

While Ozempic and Wegovy share the same active ingredient, Medicare does not cover these drugs for weight loss. In fact, Medicare Part D plans are explicitly prohibited from covering drugs used for anorexia, weight loss, or weight gain, even if they are prescribed for a non-cosmetic purpose such as morbid obesity. 

This means that Medicare beneficiaries seeking a semaglutide prescription for weight loss will need to pay out of pocket, regardless of whether they opt for branded Ozempic or Wegovy.

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Out-of-Pocket Costs for Ozempic and Wegovy

The list price for Ozempic is $935.77 for a supply of four weekly doses. This amounts to nearly $12,200 per year. Similarly, Wegovy, priced at $1,349.02 for the same duration, totals slightly over $17,500 annually. 

As patents still protect both Ozempic and Wegovy, no generic alternatives are available to reduce costs.

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The Cost Implications of Covering Weight Loss Drugs for Medicare

Bringing about a policy change to include weight loss drugs in Medicare coverage would require significant legislative action. Although bills advocating for such coverage have been introduced in each of the past six congressional terms, none have passed into law. 

One of the barriers to this change is the high cost associated with weight loss drugs. For instance, if 10% of Medicare beneficiaries with obesity were to take Wegovy, it would cost Medicare Part D approximately $26.8 billion annually, according to estimates published by researchers at Vanderbilt University School of Medicine and the University of Chicago Department of Medicine. 

To put this into perspective, 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. 

Therefore, covering Wegovy alone would cost more than twice that amount, accounting for approximately one-eighth of the total $216 billion spent on all covered Medicare Part D drugs in 2021.

In summary, it can be concluded that Medicare Part D provides coverage for Ozempic in the context of treating Type 2 diabetes, whereas its coverage does not extend to the purpose of weight loss.

Despite the growing popularity of Ozempic and its association with weight loss on platforms like TikTok, Medicare beneficiaries seeking coverage for weight loss medications, including Ozempic and Wegovy, will need to bear the costs themselves.

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