In 2003 Congress passed a Rule that distinctly prohibited Medicare Part D prescription drug benefits from covering drugs used for weight loss, along with some other types of drugs, including agents used for cosmetic purposes or hair growth, fertility drugs, and drugs prescribed to treat sexual or erectile dysfunction.
Originally approved to treat type 2 diabetes, prescription drugs known as GLP-1 (glucagon-like peptide-1) agonists, including Novo Nordisk’s Ozempic and Wegovy (semaglutide) and Eli Lilly’s Mounjaro (tirzepatide), are also often effective for weight loss. But they are also expensive, and not covered by Medicare when used for weight loss. However, if the same drug receives FDA approval for a medically accepted use such as cardiovascular disease or type 2 diabetes, it may be covered by Medicare prescription drug plans.
Recently, shortly before leaving office, President Biden expanded the list of drugs to be negotiated with Medicare to include weight loss medications. Unfortunately, this does not mean that this will happen anytime soon. Currently, there is a list of 10 drugs that are supposed to be brought to the price negotiation table in 2025. If the prices get negotiated downward, it would take effect for Jan 2026. However, right now no weight loss drugs are on that list. What President Biden did was add the weight loss medications to the next list of medications, which is to be brought to the price negotiation table in 2026. Any price differences made as a result of those future negotiations would take effect in 2027.
Currently, Wegovy’s label was approved to include cardiovascular benefits. As long as it is prescribed to reduce their risk of heart attack and stroke it may be covered. If Ozempic is prescribed to control type 2 diabetes, then it also may be covered under Medicare Part D as well. If you take Mounjaro to treat Type 2 diabetes, Medicare may provide coverage with an accepted prior authorization. This means that the plan may require the doctor to contact the plan to request authorization before the plan will cover the prescription drug. The doctor must show the plan that the drug is medically necessary for it to be covered. You may also be asked to try one or more similar lower costing drugs before other costlier drugs like Mounjaro are covered, and it’s eventual coverage is not guaranteed. This is called Step Therapy.
Your best bet is to call your insurance carrier and ask directly if your prescribed drug is included in their formulary (a list of drugs covered by the plan) and how much it will cost you out-of-pocket.
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