Does Medicare Cover Ozempic

Key Takeaways

• Medications used for weight loss can come with a significant out-of-pocket cost. These medications, such as Ozempic (semaglutide) and Zepbound (tirzepatide), can cost over $1,000 a month without insurance coverage.

• Medicare doesn’t cover Ozempic when treated through the obesity behavioral therapy pathway. This is when your BMI (Body Mass Index) is 30 or greater. This is because Medicare (Part B) does not cover any anti-obesity medications as part of its coverage policies.

• Medicare does cover Ozempic when being prescribed as a treatment for Type 2 diabetes. Medicare spending of Ozempic as part of Type 2 diabetes treatment was up to $944,028,412.86 in 2022 when compared to spending in 2021, which was $497,924,482.86.

• If you fall into the category of having a body mass index (BMI) of 30 or more, Medicare Part B (Medical Insurance) will help to cover obesity screenings and behavioral counseling. Medicare covers this counseling if your primary care doctor or other primary care provider gives the counseling in their primary care setting (like a doctor's office), where they can coordinate your personalized prevention plan with your other care.

Medicare Coverage and Ozempic (Facts)

“Ozempic” is the brand name for the drug “semaglutide,” which is a prescription medication manufactured and sold by Novo Nordisk. As an injection, it can help control blood sugar in people with Type 2 diabetes.

The FDA describes semaglutide as “a class of medications known as glucagon-like peptide-1 (GLP-1) receptor agonists. It mimics the GLP-1 hormone that is released in the gastrointestinal tract in response to eating. One role of GLP-1 is to prompt the body to produce more insulin, which reduces blood glucose (sugar).”

According to data provided by data.CMS.gov, in 2022 Medicare spending for Ozempic was $944,028,412.86, which is up significantly from spending in 2021 which was $497,924,482.86. Clearly, Medicare is covering Ozempic prescriptions. However, it’s important to consider how these prescriptions are being administered through the Medicare program.

Coverage facts you should know:

1. Medicare doesn’t cover Ozempic when treated through the obesity behavioral therapy pathway. This is when your BMI (Body Mass Index) is 30 or greater. This is because Medicare (Part B) does not cover any anti-obesity medications as part of its coverage policies.

2. Medicare does cover Ozempic when being prescribed as a treatment for Type 2 diabetes.

3. Because “Ozempic,” or semaglutide is considered an outpatient prescription drug, Ozempic falls under Medicare Part D. Complete coverage for Ozempic will differ between plans.

4. You’ll need to check your Medicare Part D “Formulary” to see what your coverage opportunities may look like.

Medicare and Obesity Behavioral Therapy

If you’re planning on getting treatment for obesity through Medicare, you’ll end up going through the “Obesity Behavioral Therapy” screening offered as part of Medicare Part B coverage. This is defined as “An initial screening for BMI, and behavioral therapy sessions that include a dietary assessment and counseling to help you lose weight by focusing on diet and exercise.” As a result of this screening you could be eligible for “Inventive Behavioral Therapy for Obesity.”

As part of the program, CMS defines the goals of the treatment plan as the following:

1. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

2. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

3. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

4. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Additional goals of the program would include the following coverage:

• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months 2-6;

• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg weight loss requirement during the first six months as discussed below.

In short, this is what you could expect from the program:

• An initial assessment to determine BMI (Body Mass Index).

• A nutritional evaluation.

• Ongoing counseling to promote long-term weight loss through dietary changes and exercise.If your objective is to treat obesity or weight loss directly, there’s a good chance that this is the type of program that you’ll be treated with. Meaning, you will not be prescribed Ozempic as part of your weight loss treatment through the Obesity Behavioral Therapy program.

However, if you’re going for treatment of Type 2 diabetes, there’s a good chance you’ll be prescribed Ozempic (or “semaglutide”) as part of your treatment plan.

Medicare Part B Coverage and Medicare Part D

It can be confusing to understand which Medicare coverage plans cover Ozempic. Here’s a simple way to understand why Ozempic would be considered as part of Medicare Part D rather than Medicare Part B:

“If you are a hospital outpatient, Part B should cover all medications that relate to the reason for your hospital visit; however, Part D will cover medications that you administer yourself and do not relate to the hospital visit.”

This information was provided from the State of Washington’s Medicare Rights center as of 2015, however, information contained within this PDF is still accurate in 2024.

Anti-Obesity Medications and Medicare Coverage

The reason why Medicare often doesn’t cover weight-loss prescription medications can actually be tracked all the way back to the 1990s. The safety and effectiveness of obesity treatments was put into question. Consequently, the Medicare Prescription Drug, Improvement, and Modernization Act was passed in 2003 and went into effect in 2006. It created the Medicare Part D prescription medication benefit and prohibited coverage for medications that were “used for anorexia, weight loss, or weight gain.” 

As a result, Medicare, which is the federal health insurance program offered in the United States for people ages 65 and older, is currently prohibited from covering medications solely for weight-loss purposes. 

However, Medicare may cover certain weight-loss (bariatric) surgeries if you are eligible based on certain requirements.