As the overall population ages, there is a growing prevalence of diabetes among adults ages 65 and older. In fact, about 16.5 million people in this age group are estimated to be living with diabetes, according to the American Diabetes Association. This demographic faces a higher susceptibility to diabetes-related complications — such as low blood sugar, kidney failure and heart disease — compared to younger individuals with diabetes.
“There is a greater understanding now about how diabetes impacts older Americans and how to treat the condition by lowering glucose levels,” says Dr. Lydia C. Alexander, chief medical officer for Enara Health in San Mateo, California. “Newer treatments are ushering in a new era of better diabetes management.”
What Is Ozempic?
Chemically known as semaglutide, Ozempic belongs to a newer class of medications — called glucagon-like peptide-1 (GLP-1) receptor agonists — used to treat Type 2 diabetes. They work by mimicking the naturally occurring hormone GLP-1 released by the body in response to food intake. This helps control blood sugar by activating the GLP-1 receptor that enhances insulin secretion and slows gastric emptying.
In one study, those taking Ozempic cut their hemoglobin A1C levels by 1.8% at the high dose compared to 1.4% with those taking another GLP-1 receptor agonist called Trulicity (dulaglutide).
Ozempic also interacts with parts of the brain to reduce appetite and increase a sense of feeling full or satiety. One study showed that individuals with an average body weight of 231 pounds lost an average of 12.4% of their body weight compared to those taking a placebo.
In June 2021, the FDA approved semaglutide (2.4 milligrams once weekly) for the treatment of chronic weight management under the brand name Wegovy.
“There is a definite correlation between Type 2 diabetes and obesity. In fact, at least 85% of Type 2 diabetes occurs in patients who are overweight or have obesity. It improves, reverses or goes into remission when weight is reduced,” says Alexander, who serves as the president-elect of the Obesity Medicine Association.
In addition to lowering blood sugar and A1C numbers and weight loss effects, Ozempic has been shown to significantly lower the risk of major adverse cardiovascular events (MACE), such as stroke or heart attack in people with Type 2 diabetes who have known cardiovascular disease.
Ozempic comes in a pre-filled pen that patients use to self-administer the medication once-weekly under the skin (subcutaneous injection) on the same day. It can be taken any time during that day with or without food.
Ozempic is considered an adjunct treatment to lifestyle modifications, such as diet and exercise.
Several common side effects of Ozempic have been identified in multiple studies, including:
— Abdominal pain.
— Constipation.
— Diarrhea.
— Fatigue.
— Nausea.
— Vomiting.
Typically, these side effects present when a dose is increased and subside after a week or two.
[READ: Do Weight Loss Pills Work? What You Need to Know]
Does Medicare Cover Ozempic?
Many people have questions about whether GLP-1 receptor agonists can help them and Medicare coverage.
Original Medicare, which consists of Parts A (hospital costs) and Part B (medical expenses), does not provide coverage of prescription drugs. That’s why most seniors enroll in Medicare Part D or Medicare Part C (Medicare Advantage) to obtain health insurance that covers the costs of prescription medications.
Medicare Part D and some Medicare Advantage plans cover Ozempic to treat Type 2 diabetes and cut cardiovascular risk in those with Type 2 diabetes and known cardiovascular disease, if deemed medically necessary by a doctor.
To determine if Ozempic is covered by your specific Medicare Part D or Medicare Advantage plan and what your costs will be, you should:
— Check your plan’s drug formulary. Each plan has a list of covered medications, called a formulary. You can review the formulary to see if Ozempic is included. Ozempic is usually considered a tier three drug, which means it is a brand-name medication with no generic versions available and it typically has a higher copayment.
— Contact your plan. You can call your Medicare Part D or Medicare Advantage plan directly to inquire about coverage for Ozempic. The plan’s customer service representatives can provide information on coverage, cost-sharing and any restrictions.
— Consult your health care provider. Your health care provider may also be able to help by providing information to support a coverage request if needed.
[READ When Do You Need a Medicare Supplemental Insurance Plan?]
How Much Does Ozempic Cost Under Medicare Plans?
The cost of Ozempic with Medicare Part D and Medicare Advantage varies depending on several factors, including:
— Your specific plan.
— Whether you have a stand-alone prescription drug plan through Medicare Part D or a Medicare Advantage plan.
— What stage of coverage you are at — such as deductible, initial coverage or the coverage gap (also known as the donut hole).
— When figuring out your potential costs, keep in mind the Inflation Reduction Act, which goes into effect this year, includes a maximum out-of-pocket spending cap for Medicare Part D beneficiaries. In 2024, the maximum that beneficiaries will pay annually for their prescription drugs is $3,333, and in 2025, the maximum will lower to $2,000.
The Inflation Reduction Act granted Medicare the authority to negotiate drug prices to reduce drug costs and help maintain the fiscal sustainability of Medicare.
Starting in 2026, Medicare can negotiate with pharmaceutical companies for 10 select drugs covered under Medicare Part D. While Ozempic was not in the 10 selected for 2026, that may change in the future. Medicare spent $4.6 billion on Ozempic in 2022, up from $2.6 billion in 2021, making it the sixth most expensive drug that Medicare covers.
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Does Medicare Cover Weight Loss Drugs?
No, under current law, Medicare cannot cover medications for weight loss.
However, according to the latest guidance from the Centers for Medicare and Medicaid Services released in March 2024, Medicare Part D plans are now allowed to cover obesity treatments that have Food and Drug Administration approval for an additional health benefit. The FDA recently approved Wegovy to treat those who are overweight or have obesity with a history of heart disease. As a result, more than 3 million Medicare beneficiaries may be eligible for Wegovy coverage, according to the Kaiser Family Foundation.
Zepbound, while being studied for heart health, currently is only approved for weight loss and, therefore, does not qualify under this guidance.
“There are multiple benefits to weight loss in all age groups — all of which involve improving overall health. Reducing obesity improves cancer risk, depression, mobility, chronic disease and increases quality of life and lifespan,” Alexander says.
According to the Centers for Disease Control and Prevention, approximately 40% of those enrolled in Medicare are obese. The Treat and Reduce Obesity Act, a new piece of legislation introduced last year with bipartisan support, will allow Medicare to cover anti-obesity medications without needing an additional indication. Whether the measure will be signed into law during a presidential election year is unknown.
If Medicare starts to cover weight loss medications, then that may influence health care insurance companies — many which have been wary of the price of the drug.
“Medicare typically affects private-sector insurance coverage,” says Dorothea Vafiadis, senior director of the National Council on Aging’s Center for Healthy Aging. “We imagine many insurers will follow suit if Medicare starts covering weight loss drugs.”
Ways to Save on Drug Costs
The high price tag of these medications makes them unaffordable for many. If you are interested in finding out what they may cost you without insurance or to potentially help lower your copay with insurance, here are a few ways to look for potential savings:
Contact the drug companies
Sometimes talking to the pharmaceutical company directly can help you determine what your options are. Call Novo Nordisk’s (Ozempic and Wegovy) customer service at 1-844-Novo4Me (1-844-668-6463) or Eli Lilly’s (Mounjaro and Zepbound) at 1-800-Lilly-Rx (1-800-545-5979) for further information.
Look online
Retail prescription websites, such as GoodRx or SingleCare, can help you find the best price. These sites monitor the price at different pharmacies and can help guide you to the most affordable option.
For example, according to GoodRx, Ozempic retails from $937 to $1,014, depending on the pharmacy you purchase from. Beware that counterfeit versions of Ozempic are available online. That means they could contain different ingredients or harmful ingredients. Only purchase medications from reputable online pharmacies. If you’re not sure, check with your doctor or pharmacist.
Manufacturer coupons
Depending on various factors including what insurance you have, you may qualify for a manufacturer coupon. This can take the price down significantly — sometimes to as little as $25 a month.
— Semaglutide. You can find information on Ozempic’s manufacturer’s coupon and Wegovy manufacturer’s coupon.
— Tirzepatide. You can also find information on Mounjaro’s manufacturer’s coupon and Zepbound’s manufacturer’s coupon.
Patient assistance programs
Many drug companies have programs available to those who may benefit but cannot afford certain medications.
— Eli Lilly (Mounjaro and Zepbound). Information on their patient assistance program can be found on the Lilly Cares Foundation website.
— Novo Nordisk (Ozempic and Wegovy). Information on their patient assistance program is available at the Novo Nordisk website.
Navigating Medicare Coverage
While Medicare is a life saver for many, understanding and navigating the complex and sometimes confounding rules can be an exercise in patience and persistence. Check the details and the fine print of the drug formulary of the plans you’re considering to make sure everything you anticipate needing will be available and covered.
Even if you’ve been a Medicare beneficiary for an extended period, it’s advisable to look at your options annually to ensure that your chosen plan remains the most suitable for your needs. Adjustments can occur yearly in plans, benefits and premiums, especially when dealing with Medicare Part D drugs or Medicare Advantage plans where you need to consider the addition or removal of medications.
While Medicare plans cover most of your health care and medication needs, there are items they will not cover. Medicare will not cover, for example:
— Deductibles and copayments.
— Health care costs for spouses and dependents.
— Long-term hospitalization.
— Medically unreasonable and unnecessary services, medications and supplies.
— Nursing home care.
Considering Medicare Advantage?
Medicare Advantage plans resemble individual health insurance policies obtained either through employer benefits or by personal enrollment in the individual insurance market. Plans vary from state to state in terms of monthly premiums, provider networks, copays, coinsurance and out-of-pocket limits.
Medicare Advantage plans typically include coverage for both hospital (Part A) and medical services (Part B) while also offering additional benefits, such as prescription medication coverage (Part D).
Some plans may also offer vision, dental, wellness programs and gym memberships.
Bottom Line
Understanding coverage for medications like Ozempic is crucial for people living with Type 2 diabetes. Medicare Part D and some Medicare Advantage plans cover Ozempic for the treatment of Type 2 diabetes and Type 2 diabetes with known heart disease, when deemed medically necessary.
While Medicare currently does not cover the cost of medications solely for weight loss, proposed legislation may change this.
New guidance from the CMS allows the coverage of weight loss medications that also have been FDA approved for another health benefit, such as heart disease. This will expand access to Wegovy to those who are overweight or obese with known heart disease.
There are several ways to help with the high cost of medications, such as contacting the manufacturers for assistance and requesting its coupons, checking online retail prices and exploring patient assistance programs.
Prescription drug coverage of diabetes and weight loss medications will vary among Medicare Advantage plans, so be sure to ask the plan directly or your insurance agent about coverage details.
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Does Medicare Cover Ozempic? originally appeared on usnews.com
Update 05/02/24: This story was previously published at an earlier date and has been updated with new information.
