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Does Medicare Cover Ozempic? 

4 mins read
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Finding the right medications that are both effective and affordable is essential, especially for senior citizens. 

A common healthcare concern for many Americans under Medicare coverage is Type 2 diabetes. Among the many available options, Ozempic is a drug that has shown great promise and generated significant interest in its ability to manage Type 2 diabetes and promote weight loss. It is an FDA-approved prescription medication that helps regulate blood sugar levels. It’s also used for chronic weight management in individuals who are overweight or obese. 

If you have Medicare, you might be curious about whether or not your plan covers Ozempic. In this article, we answer that question and provide answers to other frequently asked questions on the topic.

What Is Ozempic?

Ozempic is the brand name of a medicine made by the Danish pharma company Novo Nordisk. Its main component is Semaglutide. It is currently sold as an injectable medicine, although plans to introduce an oral version are also in the works. 

Semaglutide works by imitating the hormone glucagon-like-peptide-1 (GLP-1), which stimulates insulin production in the body and suppresses appetite. Before prescribing this drug in combination with dietary restrictions and exercise, doctors need to consider its known side effects

Type 2 diabetes is a chronic disease characterized by the body’s inability to produce or metabolize insulin – the hormone that regulates blood sugar levels. A compromised insulin function results in elevated blood sugar levels, which in turn can lead to a variety of health issues.  

Ozempic works by increasing the amount of insulin secreted by the pancreas and decreasing the amount of glucagon, a hormone that raises blood sugar levels. It also promotes a feeling of fullness and slows down stomach emptying, both of which help with weight management.

It’s worth noting that Ozempic is only recommended for use by adults with Type 2 diabetes and doctors advise against using it to treat Type 1 diabetes or diabetic ketoacidosis.

Medicare Coverage of Ozempic for Type 2 Diabetes

The Medicare plans that cover prescription drugs are Part B (Medical Insurance) and Part D (Prescription Drug coverage). 

Currently, Medicare Part B does not cover Ozempic. Coverage under this plan applies only to medications administered in healthcare facilities like hospitals or clinics. Ozempic, on the other hand, is self-administered. 

Medicare Part D, which covers prescription drugs bought from a retail pharmacy, covers Ozempic only as a treatment for diabetes. 

According to data from the Centers for Medicare & Medicaid Services (CMS), Ozempic accounted for the 10th-highest spending for any drug under Medicare Part D in 2021. It covered more than 450,000 beneficiaries that year. 

Usually prescribed at four weekly shots, a year’s dosage of Ozempic costs around $12,000. Also, because Ozempic is still patent protected, there are no cheaper generic versions of the drug. 

Medicare Part D, which offers coverage for prescription drugs that you purchase from a pharmacy, might cover Ozempic.

You can check the formulary or drug list of your Medicare Part D plan to see if it covers Ozempic. The formulary is a list of approved medications along with their prices. This data is available in the plan’s documents.

Medicare Coverage of Ozempic for Weight Loss

In addition to managing Type 2 diabetes, Ozempic also helps with weight management in people who are overweight or chronically obese. 

However, Medicare does not cover Ozempic as a weight loss treatment. In fact, Medicare does not cover any prescription drug for weight loss treatment. 

If you are considering using Ozempic for weight loss, it is advisable to talk with your doctor first to go over alternative options and potential out-of-pocket costs.

Other Coverage and Financial Assistance Options for Ozempic

If your Medicare plan does not cover Ozempic or if the out-of-pocket costs associated with its usage are too high, you might want to look into other options for financial support. 

Some pharmaceutical companies, including Ozempic maker Novo Nordisk, offer eligible individuals discounts or free medication through patient assistance programs. Check to see if you are eligible. 

Such alternatives are less expensive while still providing comparable benefits. 

It is also important to be aware of the particular restrictions and requirements of your Medicare plan when it comes to Ozempic coverage. As we’ve discussed above, Medicare Part B does not cover Ozempic. It may be covered under Part D depending on the cost-sharing guidelines of your specific plan.

You can make well-informed decisions about your diabetes management by engaging in conversations with healthcare providers and staying up to date on the latest options available.

For accurate and current information regarding the coverage and cost of Ozempic, it is always best to speak with your doctor or look for answers on the official Medicare website. 

Reach out to CoverRight for guided assistance about Medicare coverage for Ozempic or any other questions you might have.  

Frequently Asked Questions (FAQ’s)

Q. How can I determine if my Medicare Part D plan covers Ozempic?

To determine if your Medicare Part D plan covers Ozempic, follow these steps:

  • Examine the formulary or drug list for your Medicare Part D plan. If it covers Ozempic, it will specify at what tier and under what cost-sharing conditions the coverage applies.
  • Contact your insurance company If you can not find the information you need in the formulary. They can give you the most recent coverage information and answer any specific questions you may have.

Q. Are there any restrictions or limitations on the quantity of Ozempic I can receive?

Quantity limits in Medicare Part D plans are used to ensure appropriate medication use and manage costs. These limits specify the maximum amount of a specific drug that is under coverage within a specific timeframe. 

You can check your plan’s formulary or contact Medicare to see if there are any quantity restrictions on Ozempic under your Medicare Part D plan. 

Q. Can I switch Part D plans if my current plan does not cover Ozempic?

You have the choice to change to a different plan during the Medicare Annual Enrollment Period (October 15 through December 7 each year) if your current Medicare Part D plan does not cover Ozempic. You have the opportunity to review and compare various Part D plans for the right coverage options. 

Richard Chan

Richard is the Founder of CoverRight and based in New York. He is passionate about empowering consumers to take control of their health and finances. Prior to starting CoverRight, Richard had extensive experience working in financial services with over 8 years' experience in consumer lending and investment banking.

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