Does Medicare Cover Wegovy?

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

In March, the FDA approved Wegovy to cut back the chance of heart attack, stroke, and other cardiovascular problems in adults with heart disease who’ve obesity or chubby. The injectable medication, a part of a category of medication called glucagon-like peptide (GLP-1) receptor agonists, was previously approved only 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 a further medically accepted indication…may 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 profit, Part D coverage continues to be not available for anti-obesity medications when used for chronic weight management in patients who wouldn’t have the extra medically accepted indication.”

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

Why Doesn’t Medicare Cover Obesity Medication?

While another insurers will cover anti-obesity drugs without a further “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 many years old and based on concerns over the protection of weight reduction drugs like Belviq and Redux, which turned out to have unwanted effects and were pulled from the market by the FDA,” David Farber, JDa law partner specializing in healthcare within the Washington, D.C., office of law firm King & Spalding, told Verywell.

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

Lawmakers have introduced laws to permit Medicare to cover anti-obesity drugs several times, including the Treat and Reduce Obesity Act last yr. The Obesity Action Coalition is lobbying Congress concerning the laws. The chair of the organization’s Board of Directors, Kristal Hartman, says she expects it to take three to 5 years before the laws passes.

The real reason for the coverage delay, experts say, is concern over how much it is going to 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 on the Kaiser Family Foundation, told Verywell. “While the price of this laws is unknown, it’s more likely to be a barrier to implementation.”

An October 2023 blog post from the Congressional Budget Office (CBO) confirms that the agency is looking into the difficulty: “CBO has not yet produced a value estimate for laws that might expand access to AOMs [anti-obesity medications] for beneficiaries of presidency programs equivalent to Medicare, however the agency is monitoring trends in the usage of AOMs, together with their prices, effects on health, and coverage by insurance coverage.”

CBO pegged the monthly out-of-pocket cost of semaglutide (the lively ingredient in Ozempic, Wegovy, and Rybelsus) at $1,349 per 30 days, which can be over $16,000 a yr for a consumer.

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

Other Ways to Access GLP-1 Drugs

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

If you don’t have a diabetes diagnosis but you and your primary care doctor consider you’re a great candidate for a GLP-1 medication, consider taking an A1C blood test, an American Diabetes Association spokesperson told Verywell. Almost three million Americans reside with undiagnosed diabetes, half of whom have chubby. If the test confirms you will have diabetes, you’ll have a greater probability of getting coverage for medication—which may also help manage your weight.