Semaglutide for prediabetes

[LBL]

I am searching for a Medicare Part D plan that includes Wegovy or another semaglutide in their 2025 formulary for a diagnosis of pre-diabetes.  After weeks of intermittent searching I have found NO useful information from any source.  The MyMedicare plan search tool doesn't help.  The clock is ticking on the enrollment period.  I'm hoping someone in this community may know any of the following:

• a Part D plan that includes Wegovy or other semaglutide in their 2025 formulary;
• for which diagnoses Wegovy or other semaglutide is covered in that plan;
• at what level of coverage;
• whether pre-approval is required.

Any links to useful sites or documents would be also be much appreciated.

Thanks for your help!

[KarenG383691]

I have part D and was well on my journey the last 2 months since it covers the Wegovy for weight loss, no explanation was needed.

However,  on 4/425 tru.p signed an executive order for Medicare to no longer cover weight loss drugs of any kind.

It must now be processed as medically necessary to obtain thru Medicare and your doctor has to be specific according to their formula, but not to include diabetes necessarily. We are waiting for pre approval.

[KarenG383691]

Without insurance it is 1300.00, which is a total rip off by this company.

[ColoChic]

I hate to tell you, but I've been working on this for over a year. I've met with endocrinologists and have an Rx on file at pharmacy.  My cardiologist even gave me the initial dose of 0.25 in July and I definitely noticed how well this works for me. If I were diabetic, I could get Ozempic for $35/mo. Same exact medicine, just dosed differently.  Doesn't matter I've been pre-diabetic for over 10 years.  My weight, BMI, sleep apnea and cardio issues definitely 'qualify' me, but because I'm on Medicare now, there is no way in hell this will ever be covered due to its cost! Bernie Sanders is the only one on our side to get NovoNordisk to stop the insane greed and make this obtainable for those who can't afford $950-$1300/mo. Canada is now about $600/mo and Germany is $56/mo. Go figure! I'll die before I can get this life saving medicine and angry because of the obesity discrimination and greed that will not allow those who are not wealthy to obtain. Unfair!

[LBL]

Appreciate your post, ColoChic.  Your “voice of experience” modifies my expectations. One would think that keeping a prediabetic from becoming diabetic would be a worthwhile investment for Medicare.  Seems not…

[GailL1 · Accepted solution]

@LBL 

Here is a link to government info that should explain how Medicare Part D works in formulary development and answer your questions.  If you have more questions, post back again after digesting this info.

Congressional Research Service - 09/09/2024- Medicare Coverage of GLP-1 Drugs 

There are several of these types of drugs 

You have to find a Medicare Part D insurer that has whatever one of them you need on their formulary and for the specific use under which the FDA has made their approval.  

For some, there has to be a specific diagnosis of Type 2 diabetes, for others (like Wegovy) they are not approved for diabetes - type 2. It was approved for cardiovascular disease. (See the KFF link at the bottom)

None of them are for a diagnosis of obesity - Medicare does not cover that particular use of them at all at present.

Now IF you can the one you are looking for on a plans formulary and your physician can validate the reason it is being prescribed, it will most likely have some restrictions on it - pre-approval / step therapy or perhaps even quantity limits.  You would probably also have to look at the enhanced Medicare Part D plans for this coverage.  

For type 2 diabetes you will probably find Ozempic on some of the formularies - maybe.

KFF.org. 04/24/2024 - A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of Peopl... 

The problem is two-fold for Medicare and the Part D insurers - Medicare does not pay for Obesity drugs - that has long been the rule of law.  And since this drug classification is not one that is mandated by Medicare that all drugs need  be covered, then the insurers can pick a couple of other drug treatments for these [whatever] diagnosis and they have met their burden by law.  

The meds are expensive and some of them are holding out for the obesity approval cause that is by far where they will make the most money.

The chemical name of them is all the same - it is just for the different purposes for which they sought FDA approval that they are different and of course, in prescribing doseage.

You and your doc could file for an exception to get [whatever] covered if within the FDA approval but I wouldn’t hold my breath.  

I read an article the other day stating that if Medicare picked up covering drugs for Obesity - it would actually break the program because it is insurance and we share and share alike on the coverage and people are already getting upset with higher premiums to give the new benefit coverages this year.

[LBL]

Thank you, Gail1!  Much relevant and useful information in your thorough and thoughtful reply!