Is Wegovy Covered by Medicare?

Medicare is currently prohibited by the federal government from covering Wegovy and other medications when used specifically as an anti-obesity medication. However The U.S. Food and Drug Administration (FDA) has approved an indication change that allows Wegovy to be used to reduce the risk of cardiovascular events in people who have obesity and also have existing heart disease. How does this change things?

This article looks at the Medicare requirements for a Wegovy prescription with this change in indication for the drug.

? What does the FDA’s decision mean for Medicare coverage of Wegovy?

In March of 2024, the FDA approved prescription drug Wegovy only, for people with cardiovascular disease who are overweight or have obesity. In these situations, Medicare-approved doctors may prescribe Wegovy to reduce the risk of life threatening cardiovascular events, such as heart attack and stroke.

Medicare Part D plans can provide coverage because Wegovy is a self-administered medication. Original Medicare (parts A and B) does not cover Wegovy because Medicare Part B covers only doctor-administered drugs.

If you have a Medicare Advantage plan, check your health plan to make sure Wegovy is covered. Medicare Advantage plans and their associated drug coverage and costs vary by health insurance plans.

? Is it hard to get prior authorization for Wegovy?

Drug plans may require prior authorization for certain medications. In addition, certain drug plans may consider Wegovy to be a specialty or higher tier medication, which allows them to charge a higher copayment.

Even if plans do allow coverage, people who meet the criteria may still face other restrictions. Plans may require higher out-of-pocket costs, prior authorizations or step therapy, in which a patient is required to try a lower-cost drug before proceeding to the new treatment,

? How much does Wegovy cost under Medicare?

The exact cost of Wegovy under Medicare Part D and Medicare Part C (Advantage plans) varies based on the prescription benefits your plan offers. Medicare Part D and Advantage plans have different monthly premiums, deductibles, and copayments.

This Medicare comparison tool can also help you compare Medicare drug plans and their costs.

? What is Wegovy?

Wegovy is a prescription weight loss medication manufactured by drug maker Novo Nordisk. It is used for chronic weight management in adults who have been overweight or obese for at least 6 months and have at least one weight-related condition such as high blood pressure, type 2 diabetes or high cholesterol.

? How does Wegovy work?

Wegovy contains the active ingredient semaglutide. Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist used as an anti-obesity drug. GLP-1 receptor agonists are found in the intestines, pancreas and brain and are part of the body’s hormone system, which regulates appetite, making it an effective target for treating obesity. When semaglutide binds to GLP-1 receptors, it increases the glucagon concentration in the blood, reducing food intake by decreasing hunger levels and speeding up digestion.

In clinical trials, treatment with semaglutide has led to significant weight loss in obese patients when combined with healthy lifestyle changes such as calorie restriction and increased physical activity. As a result, weight loss drug Wegovy is becoming an increasingly popular option for weight loss.

? How can Wegovy help with heart disease?

The effect of Wegovy on the risk of major cardiovascular events such as death, heart attack, or stroke was studied in adults with known heart disease who were either overweight or had obesity, and compared with those on placebo (an inactive injection). Individuals taking Wegovy experienced a 20% reduction in major adverse cardiovascular events (MACE) compared to those taking a placebo, making the findings particularly significant.

? What are the common side effects of Wegovy?

Taking Wegovy has been associated with some mild side effects, including bloating and pain in the abdomen area, burping, diarrhoea or constipation, dizziness, gas discomfort, headaches and feelings of fatigue. Other discomforts after taking this medication are indigestion/heartburn and stomach flu-like symptoms, such as nausea and vomiting.

? Conclusion

Wegovy is a type of medication that doctors primarily prescribe as a weight loss drug. Medicare does not provide coverage for Wegovy for weight loss or weight management.

However, Medicare does provide coverage for Wegovy when a Medicare-approved doctor prescribes it to help reduce risk of heart attacks and other cardiovascular events in adults with obesity or who are overweight.

More indications for GLP-1 drugs are on the horizon, which means more insurance coverage may be too.

Sources

• FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults with Obesity or Overweight – FDA
• Explore your Medicare coverage options
• Wegovy (semaglutide): a new weight loss drug for chronic weight management – NCBI
• How Does Wegovy® Work? – Wegovy® (semaglutide) Injection 2.4 mg