Does Medicare Cover Wegovy?

Fact checked by Nick Blackmer

Key Takeaways

• Medicare now covers the injectable anti-obesity drug Wegovy for reducing cardiovascular risks in patients with heart disease and obesity, following its FDA approval for this specific use.

• Despite the broader availability of Wegovy, Medicare’s coverage for anti-obesity medications remains limited to those with additional medically accepted indications, due to longstanding legislative restrictions.

• The high cost of anti-obesity drugs and the uncertain impact on overall healthcare spending are major barriers to expanding Medicare coverage for these medications.

By law, Medicare doesn’t cover any weight loss or anti-obesity drugs. But one Food and Drug Administration (FDA) indication at a time, that could start to change.

In March, the FDA approved Wegovy to reduce the risk of heart attack, stroke, and other cardiovascular problems in adults with heart disease who have obesity or overweight. The injectable medication, part of a class of drugs called glucagon-like peptide (GLP-1) receptor agonists, was previously approved just for weight management.

The heart disease indication means Medicare Part D plans can cover the drug.

“CMS is clarifying that anti-obesity medications that receive FDA approval for an additional medically accepted indication…can be considered a Part D drug for that specific use,” said a memo issued by the Center for Medicare and Medicaid Services (CMS). “Unless provided as a supplemental benefit, Part D coverage is still not available for anti-obesity medications when used for chronic weight management in patients who do not have the additional medically accepted indication.”

Now, pharmaceutical companies are researching other conditions that obesity medications can treat in order to earn more FDA indications, potentially expanding insurance coverage. In April, for instance, Eli Lilly announced study results demonstrating Zepbound significantly improved symptoms of obstructive sleep apnea.

Related: Ozempic May Help Treat Conditions Beyond Diabetes and Obesity

Why Doesn’t Medicare Cover Obesity Medication?

While some other insurers will cover anti-obesity drugs without an additional “medically accepted condition,” the Medicare Modernization Act of 2003 still prohibits it. Medicare Part D and Medigap plans are also unlikely to cover them.

“That decision is decades old and based on concerns over the safety of weight loss drugs like Belviq and Redux, which turned out to have side effects and were pulled from the market by the FDA,” David Farber, JD, a law partner focusing on healthcare in the Washington, D.C., office of law firm King & Spalding, told Verywell.

It’s not just the injectable anti-obesity drugs that Medicare doesn’t cover; plans also don’t cover older oral weight management drugs such as Xenical. These medications don’t help people lose weight quite as quickly as GLP-1s like Wegovy or Zepbound, but they’re still very effective, Dina Griauzde, MD, an obesity specialist at Michigan Medicine, told Verywell.

Lawmakers have introduced legislation to allow Medicare to cover anti-obesity drugs several times, including the Treat and Reduce Obesity Act last year. The Obesity Action Coalition is lobbying Congress about the legislation. The chair of the organization’s Board of Directors, Kristal Hartman, says she expects it to take three to five years before the legislation passes.

The real reason for the coverage delay, experts say, is concern over how much it will cost the healthcare system.

“Authorizing Medicare coverage of anti-obesity drugs seems unlikely at this point,” Juliette Cubanski, PhD, MPP, MPH, deputy director of the Program on Medicare Policy at the Kaiser Family Foundation, told Verywell. “While the cost of this legislation is unknown, it’s likely to be a barrier to implementation.”

Related: How to Continue Taking Mounjaro or Ozempic When You Can't Afford It

An October 2023 blog post from the Congressional Budget Office (CBO) confirms that the agency is looking into the issue: “CBO has not yet produced a cost estimate for legislation that would expand access to AOMs [anti-obesity medications] for beneficiaries of government programs such as Medicare, but the agency is monitoring trends in the use of AOMs, along with their prices, effects on health, and coverage by insurance plans.”

CBO pegged the monthly out-of-pocket cost of semaglutide (the active ingredient in Ozempic, Wegovy, and Rybelsus) at $1,349 per month, which would be over $16,000 a year for a consumer.

“Medicare’s coverage of AOMs at their current prices…would increase overall federal spending,” CBO said. That could result in higher premiums—the monthly amount Medicare recipients pay for their plans.

Takeaway

While the Congressional Budget Office said it will continue to examine how much anti-obesity medications will cost or save Medicare in the long run, it is not currently aware of research that suggests the drugs will improve health outcomes enough to decrease healthcare spending for related conditions.

Other Ways to Access GLP-1 Drugs

While Medicare can’t cover obesity medication, it can cover similar drugs used to treat type 2 diabetes. Both Ozempic and Mounjaro are eligible for Medicare coverage, and both work in part by controlling insulin release and delaying gastric emptying to modulate blood sugar. A byproduct of those mechanisms of action is weight loss.

If you don’t have a diabetes diagnosis but you and your primary care doctor believe you are a good candidate for a GLP-1 medication, consider taking an A1C blood test, an American Diabetes Association spokesperson told Verywell. Almost three million Americans are living with undiagnosed diabetes, half of whom have overweight. If the test confirms you have diabetes, you’ll have a better chance of getting coverage for medication—which might also help manage your weight. 

What This Means For You

If you have obesity or overweight and heart disease, the new Medicare coverage for Wegovy might offer you a valuable treatment option. It’s important to discuss with your healthcare provider whether this medication could be suitable for you. More indications for GLP-1 drugs are on the horizon, which means more insurance coverage may be, too.

Read the original article on Verywell Health.