Ozempic (semaglutide) is a medication used in the treatment of diabetes, which has grown in popularity due to its efficacy in weight management. For seniors considering Ozempic for diabetes or weight loss, you may be wondering about Medicare coverage of the drug. This article will review the cost of Ozempic under Medicare and discuss other services covered by Medicare for diabetes management.
What is Ozempic?
Ozempic (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist medication for type 2 diabetes. It is an injectable medication taken once weekly that helps control blood sugar levels by mimicking GLP-1, which is naturally produced in the body. GLP-1 stimulates insulin release in response to elevated blood glucose levels, which in turn lowers your blood sugar.
It also slows stomach emptying, which causes a feeling of fullness and helps with weight loss. These benefits in addition to the benefits for the heart have led to increased utilization of Ozempic for the management of diabetes.
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Who needs Ozempic?
GLP-1 receptor agonists like Ozempic are recommended by the American Diabetes Association for patients with diabetes who also have atherosclerotic heart disease, heart failure, and chronic kidney disease. They also recommend Ozempic for obese individuals with diabetes who are 55 and older as it has demonstrated efficacy in assisting with weight loss.
The CDC anticipates that 20% of Americans will be 65 and older by 2030, and since older adults are at an increased risk of having multiple chronic diseases, medications such as Ozempic may be beneficial for older adults managing these comorbidities.
Medicare coverage for Ozempic
Ozempic is approved by the Food and Drug Administration (FDA) to be used alongside diet and exercise to improve blood glucose levels in patients with diabetes. It is also FDA-approved to reduce the risk of cardiovascular events like heart attack and stroke in patients with or without type 2 diabetes who also have cardiovascular disease.
Some Medicare plans will cover Ozempic for the treatment of these two conditions, and more information is detailed below.
Does Medicare cover Ozempic?
For Medicare to cover Ozempic, certain criteria should be met. In general, the medication should be prescribed for the treatment of diabetes and determined to be medically necessary. This means that Ozempic is necessary for the treatment of your diabetes and meets acceptable medical standards for effective care.
It should also be noted that Medicare does not cover Ozempic or any other medications for the treatment and management of weight loss alone. Medicare typically covers medications such as Ozempic when they are used to treat obesity-related conditions like diabetes.
Furthermore, Ozempic is not FDA-approved for the treatment of weight loss. Wegovy is a higher-dose injectable formulation of semaglutide approved by the FDA for weight management. It is approved for use in conjunction with a low-calorie diet and increased physical activity in adults with obesity. Wegovy may be covered by other private health insurers that cover weight loss drugs. Similar to Ozempic, Wegovy is not covered by Medicare for the treatment and management of weight loss alone.
Which part of Medicare covers Ozempic?
Medicare prescription drug coverage is generally provided by a Medicare Part D plan or a Medicare Advantage plan, which is also known as Medicare Part C. Medicare Part D is the part of Medicare that covers prescription drugs. Since Ozempic is a prescription drug, it may be covered by one of those plans if prescribed for diabetes or to reduce cardiovascular risk in patients with heart disease.
Additionally, Medicare Part D plans are issued by private insurance companies, and coverage and cost-sharing requirements vary among plans. If you have a Medicare Part D plan, review your plan’s formulary to determine if Ozempic is covered for your condition.
Private insurance companies approved by Medicare offer Medicare Advantage plans (Part C). These plans provide the same coverage as Original Medicare (Parts A and B) and often include additional benefits, such as prescription drug coverage through Medicare Part D. Check to see if your plan includes Medicare Part D, and if it does, review the specific details of your plan's formulary to see if Ozempic is covered or contact the insurance company for more information.
How to get Ozempic covered by Medicare
Once you enroll in a Medicare drug plan, there still may be several requirements that must be met before your insurance company will approve Ozempic.
Your plan may require prior authorization or step therapy before approval. It's important to consult with your healthcare provider and review your specific Medicare plan's guidelines to determine if you meet the coverage criteria for Ozempic under your plan. More information on enrolling in a Medicare Part D plan and additional requirements for prescription drug coverage is below.
Enrolling in a Medicare Part D plan
One of the first steps to obtaining coverage through Medicare is to enroll in a prescription drug plan such as Medicare Part D. It is best to enroll in a Medicare Part D plan after enrolling in Original Medicare (Parts A and B). As there are a variety of plans to choose from, it is a good idea to compare plans and select the one that best meets your prescription coverage needs.
If your Medicare Part D plan does not meet your needs, you can consider changing plans during the Medicare open enrollment period, which is open from October 15 to December 7 each year.
Understanding formularies
Medicare drug plans typically have a list of covered medications, known as a formulary. This list includes both brand-name and generic drugs, often organized into different cost categories or tiers. To find out if Ozempic is covered and its estimated cost, you can either contact your insurance provider or check your plan's formulary online.
Prior authorization and step therapy
Some medications require submission of documentation from your doctor to your insurance company before the insurance company will approve the medication. This process is known as the prior authorization process, and it helps insurance companies manage costs and utilization of drugs. If prior authorization is required for you to receive Ozempic, your provider will need to demonstrate that the medication is medically necessary for your condition.
Additionally, your insurance company may require you to try a less expensive, preferred medication before covering Ozempic. This is known as step therapy, and Ozempic may only be covered after the preferred medication has been tried and found ineffective by your prescriber.
Costs associated with Ozempic under Medicare
Several health insurance companies provide coverage for Ozempic (semaglutide) under their Medicare plans. However, the coverage and cost of Ozempic will vary among different plans.
Depending on your plan, your monthly out-of-pocket cost can be less than $100, or it could be several hundred dollars. Additionally, if you have a deductible, which is the amount you must pay before your insurance coverage starts, that can affect the amount you pay for Ozempic.
You can compare plans and review the formulary and coverage details or contact the insurance company to determine if Ozempic will be paid for under a particular insurance company's plan. They can provide the most accurate and up-to-date information regarding the coverage options for Ozempic under their specific Medicare plans.
Financial assistance programs
If you need assistance covering the cost of your Ozempic prescription, the manufacturers of Ozempic offer a patient assistance program. This program is open to individuals with Medicare or those who are uninsured. To qualify you must be a U.S. citizen or legal resident and have a total household income at or below 400% of the federal poverty level.
Another option is the Extra Help program, which helps lower Medicare Part D costs for people with limited income. People who qualify for Extra Help in 2024 will pay no out-of-pocket costs for their prescription drug plan premium or deductible.
Managing diabetes with Medicare: key considerations for seniors and caregivers
Diabetes is a complex condition, and in addition to medication management with drugs such as Ozempic, a comprehensive care plan is needed to effectively manage the condition. Medicare offers coverage for various services related to diabetes management. This coverage includes:
- Doctor visits. Medicare covers visits to healthcare professionals, including endocrinologists and diabetes specialists.
- Diabetes supplies. Medicare Part B covers certain diabetes supplies, such as glucose meters, test strips, lancets, and insulin pumps.
- Self-management training. Medicare provides coverage for diabetes self-management training to help individuals learn how to manage their condition effectively.
- Preventive services. Medicare covers various preventive services related to diabetes, including annual wellness visits, eye exams, and foot exams.
- Medications. In addition to Ozempic, Medicare Part D can cover a variety of other medications for the treatment of diabetes such as insulin.
- Medical nutrition services. If determined appropriate by your doctor, you may be able to receive nutrition counseling and tips on how to manage a healthy lifestyle from a registered dietician.
These coverage options are available under Original Medicare (Parts A and B) and Medicare Advantage plans. Be sure to review your specific plan's coverage details regularly to understand the extent of coverage for diabetes treatment.
Medicare coverage of Ozempic will depend on your specific Medicare Advantage, or Medicare Part D plan. Review your plan's formulary and coverage details and consult with your healthcare provider and insurance company to determine the coverage and cost of Ozempic under your specific Medicare plan.
FAQ
Can Ozempic (semaglutide) really help with weight loss?
Ozempic (semaglutide) effectively promotes weight loss. It reduces appetite and slows stomach emptying, resulting in significant weight loss in individuals without diabetes. Coverage for Ozempic as a weight loss treatment may differ from its coverage for diabetes. Consult your healthcare provider and insurance company to determine if Ozempic is suitable for weight loss and if coverage is available.
What should I do if my Medicare plan doesn't cover Ozempic?
You can consider switching your plan during the Open Enrollment period. Alternatively, you can file with your insurance company. You or your doctor can write a letter to your company explaining why Ozempic should be covered. Your insurance company may consider making an exception. Contact your plan to learn more about the appeals process.
How do I get Ozempic for $25 a month?
The manufacturer of Ozempic offers an Ozempic savings card to eligible commercially insured patients. With this savings card, you may be able to obtain Ozempic for $25 per month for up to 24 months. Patients with prescription drug coverage provided by Medicaid, Medicare, Medigap, or other government programs are ineligible.
Will Medicare Part B cover Ozempic (semaglutide)?
Medicare Part B covers Ozempic (semaglutide) when administered in a medical facility. As Part B covers medical services and supplies, medications given during office visits or hospital stays are usually eligible. Confirm coverage details for Ozempic under Part B with your Medicare plan or healthcare provider, as policies can vary. If not covered by Part B, consider Medicare Part D or Medicare Advantage plans for alternative coverage options.
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Ozempic (semaglutide) is a medication used for treating type 2 diabetes.
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Medicare coverage for Ozempic depends on the specific Medicare plan you have and is generally covered by Medicare Advantage and Part D.
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The cost of Ozempic with Medicare will vary depending on your insurance plan and whether the medication is covered.
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If you cannot afford your prescription for Ozempic, you may be eligible for the Extra Help program or a patient assistance program.
7 resources
- The New England Journal of Medicine. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes.
- JAMA Network. Medications for obesity: a review.
- American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of care in Diabetes—2024.
- U.S. Centers for Medicare and Medicaid Services. What Part B covers.
- U.S. Centers for Medicare and Medicaid Services. What Medicare Part D drug plans cover.
- U.S. Centers for Medicare and Medicaid Services. Medicare coverage of diabetes supplies services, and prevention programs.
- U.S. Centers for Medicare and Medicaid Services. Help with drug costs.
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