Some people may be eligible for Medicare coverage for Wegovy if they meet medical criteria for heart disease risk. However, Medicare does not cover medications that are strictly for weight management.
Wegovy is a type of weight management or weight loss medication. Doctors may prescribe it to help people with obesity lose weight. However, they also prescribe it for other health conditions.
Medicare does not cover treatments for weight loss because lawmakers have deemed it a cosmetic therapy. However, Medicare does cover medically necessary treatments, such as treatments for heart disease. Healthcare professionals may prescribe Wegovy to prevent cardiovascular events in certain individuals.
This article discusses Medicare coverage for Wegovy in more detail, including the cost of Wegovy with Medicare, and Medicare coverage for other glucagon-like peptide-1 (GLP-1) agonist drugs.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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Wegovy is a semaglutide, which is a type of GLP-1 agonist.
The approval came following results from a 2023 study that found, in comparison with a placebo, people with cardiovascular disease and obesity or overweight without diabetes who received a weekly semaglutide injection at a dose of 2.4 milligrams (mg) had a reduced risk of cardiovascular death, non-fatal heart attack, and non-fatal stroke.
The 2003 law establishing Medicare Part D (drug coverage) prohibits the coverage of drugs used for weight loss, deeming them for cosmetic rather than medical use.
In other words, people interested in using Wegovy for weight management alone will not qualify for coverage from Medicare and will need to pay out of pocket.
Medicare Part D may cover Wegovy for specific purposes, such as for the treatment of diabetes and for the prevention of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and either obesity or overweight. However, this depends on individual Medicare plans, so a person should discuss their coverage details with their providers.
The Kaiser Family Foundation (KFF) reports that data from 2020 indicated that about 7% of Medicare beneficiaries or about 3.6 million people may qualify for Medicare coverage for Wegovy.
Of those eligible people, 1.9 million were also living with diabetes and would have already had qualifying coverage for Wegovy and similar medications.
Medicare resources
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In the United States, the KFF and the Petersen Center on Healthcare report that the list price for Wegovy is $1,349 per month as of 2023. The term “list price” refers to Wholesale Acquisition Cost (WAC) or the cost charged from a manufacturer to a wholesaler or other direct purchaser. This price refers to the cost before the application of discounts or other exclusions. The out-of-pocket cost will depend on a person’s pharmacy.
Medicare Part D and Medicare Advantage plans may cover Wegovy as a specialty tier medication. This means a person may have to pay between 25% and 33% coinsurance. This amounts to approximately $325 to $430 per month.
A person would need to pay this coinsurance until they meet the annual out-of-pocket drug spending amount. In 2024, the amount is $3,300. In 2025, the amount will lower to $2,000 due to the Inflation Reduction Act.
Once a person reaches their maximum through Wegovy or other medications, they would no longer need to pay the coinsurance until the end of the calendar year.
However, these numbers are estimates only. Several factors, such as plan details, a need for preauthorization, and how Wegovy gets classified, will all affect how much a person will end up paying for Wegovy if they meet eligibility criteria.
Medicare may cover some GLP-1 agonist drugs, but only if a person has certain medical conditions that make it a medical necessity.
People living with diabetes already had coverage for GLP-1 agonist medications to help with treatment of diabetes. If other medical uses become apparent, Medicare may expand its drug coverage for other uses as needed.
Similar GLP-1 agonist medications may also gain approval for the prevention of heart disease complications as well, which could expand Medicare’s coverage. Other GLP-1 agonist drugs include Rybelsus, Ozempic, and Mounjaro.
A person interested in Wegovy or similar medications should consider discussing their eligibility with a healthcare professional to determine if they have a medically necessary reason for coverage.
Wegovy is a type of GLP-1 agonist, doctors primarily prescribe it as a weight loss medication. However, Medicare only covers Wegovy for the prevention of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and either obesity or overweight.
Even with Medicare coverage, the cost for Wegovy may still be several hundred dollars per month until a person reaches the out-of-pocket maximum each year.
Other GLP-1 agonist medications may also gain Medicare coverage. However, they also require a person to have a medically appropriate reason to take the medication beyond weight loss.