Does Medicare Cover Weight Loss Drugs Like Ozempic or Mounjaro?
Millions of people have begun using drugs like Mounjaro and Ozempic, mainly intended to control diabetes, to manage their weight. In addition, Wegovy, a formulation of the same drug in Ozempic, was marketed for weight loss, but the U.S. Food and Drug Administration has now also approved the medication for lowering the risk of heart disease. If you’re currently enrolled in Medicare or becoming eligible soon, you should understand why accessing one of these drugs specifically to lose weight may be difficult and what other coverage is available to you.
What Weight Is Right for Older Adults?
The most recent data available from the Centers for Disease Control and Prevention (CDC) shows that just under 42% of U.S. adults are obese. The CDC defines obesity as a body mass index (BMI) — calculated by dividing a patient’s weight by their height — of over 30, significantly higher than the range of 18.5 to under 25 that medical professionals consider healthy.
There’s a wide variety of chronic conditions associated with obesity, like heart disease, type 2 diabetes, stroke, autoimmune diseases, and certain cancers. As a result, healthcare providers often consider weight a serious concern.
Before embarking on any weight loss plan, talk with your doctor about your overall health. Medical professionals will consider your BMI along with other health factors such as your blood pressure, cholesterol levels, and blood sugar to determine if you’re at a healthy weight.
Even if your BMI looks a little high, that does not necessarily mean you need to start shedding pounds. Research shows that being moderately overweight by the standards used for younger people can actually become beneficial as we age. A little excess fat might protect you from breaking a bone when you fall or provide stores of energy to help you through treatments for serious illnesses.
When discussing your health with medical professionals, it’s important that you feel supported and respected, no matter what you weigh. There’s evidence that, just like other people in U.S. society, healthcare providers often have a biased perspective on heavier people, which may become apparent through insensitive language or a lack of comfortable accommodations in the office. If you feel you have experienced biased treatment, Harvard Medical School suggests advocating for yourself by speaking directly to your provider and their staff about the issue.
Weight Loss Drugs and Medicare
People on Medicare can enroll in a variety of Part D prescription drug plans or a Medicare Advantage plan with drug coverage. Each of these plans from private insurance carriers is different, with its own formulary (a list of covered medications), and costs for coinsurance, monthly premiums, and annual deductibles. However, federal regulations exclude certain pharmaceuticals from coverage by any Medicare plan, including prescriptions for weight loss, weight gain, or the treatment of anorexia.
That means, while Medicare Part D or Medicare Advantage plans do cover medications used to manage diabetes or prevent heart disease, they will not cover drugs that are specifically prescribed for weight loss. Drug manufacturers may offer discount cards or coupons to lower the costs of medications that are not covered by insurance (these discounts cannot be used for covered drugs). Some Medicare Advantage or Part D plans offer their own discount cards, but these can only be used for covered medications.
Since drugs like Ozempic, Wegovy, and Mounjaro are currently sold by their manufacturers at high list prices, the lack of Medicare coverage could make them too expensive for many people, even after applying a manufacturer’s discount.
How Medicare Can Support Weight Loss
There is help available to people on Medicare who want to lose weight. If you’re considered obese, Medicare Part B and Medicare Advantage plans cover screening and behavioral counseling from your primary care provider at no cost. Your provider will guide you to plan changes in your eating habits and activities, set goals, and develop the necessary skills, confidence, and support system to succeed.
Medicare covers weekly counseling visits for the first month, then biweekly visits through the sixth month. If you lose at least 3 kilograms (6.6 pounds) during this time, coverage for monthly visits will continue for another six months.
People on Medicare who are severely obese and who have been unsuccessful with other forms of treatment may be able to undergo bariatric surgery. To have a procedure such as gastric bypass surgery or laparoscopic banding surgery covered, your BMI must be over 35 and you need to be diagnosed with at least one comorbidity (another medical condition associated with obesity).
Medicare Advantage plans may provide supplemental benefits that could be a big help in managing your weight. Many plans include access to gyms as well as to fitness programs you can participate in from home. Some people qualify for assistance with buying groceries and over-the-counter items that could help you get better nutrition.
Everyone’s body is different, and you should set the diet and exercise goals that make sense for you. Weight is just one of many factors that can affect your well-being as you age, so engage with your healthcare provider and seek out support as you pursue a healthy lifestyle in the years ahead.
About GoHealth
GoHealth is a leading health insurance marketplace and Medicare-focused digital health company. Enrolling in a health insurance plan can be confusing for customers, and the seemingly small differences between plans can lead to significant out-of-pocket costs or lack of access to critical medicines and even providers. GoHealth combines cutting-edge technology, data science, and deep industry expertise to build trusted relationships with consumers and match them with the healthcare policy and carrier that is right for them. Since its inception, GoHealth has enrolled millions of people in Medicare plans and individual and family plans. For more information, visit GoHealth.com.
