Semaglutide (brand name Ozempic) is a medication that was first developed to treat type 2 diabetes. While it was effective in controlling blood sugar, it was also found to decrease appetite and promote weight loss. One study found that people lost as much as 6% of their weight within three months and up to 11% in six months of taking it.
Unfortunately, Medicare covers this medication only in certain situations. For example, Ozempic is covered for the treatment of type 2 diabetes; it is not covered for the purpose of weight loss. Ozempic Generic
This article will discuss the conditions for which Medicare covers Ozempic, when it does not, and how to get savings on Ozempic if not covered by your health insurance.
Medicare covers medications that it considers to be medically necessary. This includes most drugs approved by the Food and Drug Administration (FDA) for certain indications, which include a diagnosis, illness, injury, syndrome, or condition.
Ozempic is an injectable medication in the class of drugs known as glucagon-like peptide agonists (GLP-1 medications). It has an FDA-approved indication for type 2 diabetes and for cardiovascular-event reduction in people who have both type 2 diabetes (the body cannot properly regulate and use blood sugar as fuel) and known cardiovascular disease (conditions affecting the heart and blood vessels).
Many Medicare Part D plans will cover Ozempic for beneficiaries who have these conditions.
In some cases, medications are used off-label. This means a healthcare provider prescribes a medication for a different medical indication than approved by the FDA, or at a different dose, frequency, or administration.
The Centers for Medicare and Medicaid Services (CMS) may allow coverage for medications for off-label use if that treatment is accepted as reasonable care, if it has medical research to back it up, and if it is accepted as a standard of practice in the medical community.
Having obesity can increase your risk for a number of medical conditions, including heart disease, diabetes, and sleep apnea (breathing repeatedly stops and starts while sleeping), among others. For some people, lifestyle modifications like diet and exercise are not always enough to decrease those risks. That is why many people turn to medications like semaglutide to help with weight loss.
Obesity is a medical condition defined by excess fat in the body. According to the Centers for Disease Control and Prevention (CDC), almost 42% of adults in the United States have obesity. "Obesity" is medically defined as a body mass index (BMI) greater than 30.
BMI is a calculation based on weight and height. It is considered a flawed measurement since it does not take into consideration many other factors affecting body mass.
When the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created Medicare Part D, it included a rule that medications could not be covered for cosmetic reasons or for the purposes of weight loss. This, unfortunately, limits how Ozempic is covered, and if you do not have type 2 diabetes, Medicare Part D will not cover it.
Like Ozempic, Wegovy is brand-name version of the drug semaglutide. Unlike Ozempic, its FDA indication is not for type 2 diabetes but for chronic weight management. Because the drug is for weight loss, Medicare does not cover it.
Incidentally, the MMA was passed before the American Medical Association (AMA) designated obesity as a disease in 2013.
With rising rates of obesity and obesity-related complications, the AMA in 2023 argued for coverage of obesity treatment. It stated, “The AMA will urge health insurers to provide coverage of available FDA-approved weight-loss medications, including GLP-1 medications, to demonstrate a commitment to the health and well-being of our patients.”
A 2023 analysis by the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California (USC) looked at the potential effects drugs like this could have on the healthcare system. They estimated that Medicare could save as much as $245 billion over 10 years if it expanded coverage to include weight loss treatments.
Although there is an upfront cost to using these medications, treatment targeted to weight loss would decrease obesity-related complications, treatments for those conditions, and the need for hospitalization. With more potential savings than spending, it is possible that Medicare could reconsider the decision to cover weight loss medications in the future.
As a brand-name drug, Ozempic can be quite expensive. Novo Nordisk, the pharmaceutical company that makes the drug, notes that each Ozempic auto-injector pen costs a retail price of $937. Depending on the dose you take, you may have to pay more or less than this amount each month.
If you are fortunate enough to have insurance, your out-of-pocket costs could be much lower. This assumes your healthcare plan covers the drug.
Because the GLP-1 class of medications is more expensive than many other classes of antidiabetic drugs, your Part D plan may require your healthcare provider to verify why Ozempic is medically necessary for you before it will cover the drug. This is known as prior authorization.
Your plan may also require you to try other lower-cost medications first as a way to keep costs down. This is known as step therapy.
Speak with your healthcare provider to make sure that they have all the information needed for Medicare to cover Ozempic. A diagnosis of type 2 diabetes is essential, but a BMI calculation should be included in any documentation to your Part D plan to improve your odds of coverage.
Novo Nordisk offers a savings card that can reduce the cost of Ozempic to as little as $25 per month. To take advantage of this program, you must have commercial insurance, and you cannot be on Medicare or Medicaid.
Because there are no savings opportunities for people who do not have insurance or for people using federal programs, equal access for all is not possible.
If you are on Medicare, you should determine if you qualify for the Part D Low Income Subsidy, referred to as Extra Help. This can decrease how much you pay for your medications in deductibles, coinsurance, or co-pays during the year. Thanks to the Inflation Reduction Act, more people will be eligible for the subsidy program in 2024.
All formulations of semaglutide, including the following, promote weight loss, not just Ozempic:
Other GLP-1 medications can also promote weight loss. Mounjaro (tirzepatide) is one such medication. With an FDA-approved indication for type 2 diabetes, Medicare Part D may cover it. Its manufacturer, Eli Lilly, reports a list price of $1,069 per month. Like Ozempic, discount cards are available for people who are insured but not for those who are on Medicare or Medicaid.
Ozempic and other GLP-1 medications are effective weight loss medications that may or may not be covered by Medicare Part D. Because current legislation does not allow Medicare Part D to cover weight loss medications, these drugs will only be covered when they are used to treat diabetes.
That could change as professional organizations lobby for coverage of weight-loss medications by Medicare in the future.
Ghusn W, De la Rosa A, Sacoto D, et al. Weight loss outcomes associated with semaglutide treatment for patients with overweight or obesity. JAMA Netw Open. 2022;5(9):e2231982. doi:10.1001/jamanetworkopen.2022.31982
Centers for Medicare & Medicaid Services. Local coverage determination: drugs and biologicals, coverage of, for label and off-label uses.
Centers for Disease Control and Prevention. Health effects of overweight and obesity.
Stierman B, Afful J, Carroll MD, et al. National Health and Nutrition Examination Survey 2017–March 2020 prepandemic data files—development of files and prevalence estimates for selected health outcomes. Natl Health Stat Report. 2021;158. doi:10.15620/cdc:106273
University of Southern California, Leonard D. Schaeffer Center for Health Policy & Economics. Benefits of Medicare coverage for weight loss drugs.
Luli M, Yeo G, Farrell E, et al. The implications of defining obesity as a disease: a report from the Association for the Study of Obesity 2021 annual conference. EClinicalMedicine. 2023;58:101962-101962. doi:10.1016/j.eclinm.2023.101962
American Medical Association. AMA urges insurance coverage parity for emerging obesity treatment options.
Novocare. Find out the cost of Ozempic.
Novocare. Ozempic (semaglutide) injection 0.5mg, 1 mg, or 2 mg savings offer.
Social Security Administration. Apply for Medicare Part D Extra Help program.
Novocare. Diabetes savings card program.
Novo Nordisk. Oral semaglutide 50 mg achieved 15.1% weight loss (17.4% if all people adhered to treatment) in adults with obesity or overweight in the OASIS 1 trial.
Eli Lilly. Mounjaro cost information.
By Tanya Feke, MD Tanya Feke, MD, is a board-certified family physician, patient advocate and best-selling author of "Medicare Essentials: A Physician Insider Explains the Fine Print."
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