Weight Loss Drugs not being covered

[kgirl]

My physician has prescribed Wegovy for increasing adverse heart related conditions which continue to deteriorate. I have AARP Preferred Part D drug plan and was denied despite showing my Calcium Score being 191 along with elevated heart rate, angina, dyslipedemia and many other heart related symptoms in addition to a BMI of 34, sleep apnea and elevated risk of stroke. With this drug proven to improve my chances of improving my health and prevent a stroke or heart attack, why to I get denied coverage? Do I have to experience an adverse heart event to be approved?

[GailL1]

@kgirl 

Was Wegovy on the plans formulary?  

[SpringIsHereVA]

[Wednesday 3/5/25] @GailL1 , out of curiousity - are these types of drugs (weight loss) covered by Medicare? NOT prescribed any, just wondering. As usual, NO pressure to respond. Take care, Nicole  👵

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[*** @GailL1 wrote 2/18/25:

@kgirl 

Was Wegovy on the plans formulary?  ***]

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[maggie539]

 I have the same question.  From what I have read, none of the weight loss injections are covered.  My Cardiologist suggested I get it, my endocronologist thinks I should, but I don't think it's covered.  I have elevated sugar, I am over weight, and am taking BP meds,  I would think I would qualify

[GailL1]

@maggie539 

On April 4, 2025, CMS made the decision NOT to include weight loss medications in the Medicare Part D program for 2026 - only the ones that are for other ailments as I listed previously will remain covered.  CMS is just not opening up Medicare to coverage of weight loss drugs for that purpose only.

[GailL1]

@maggie539 

Medicare only covers some of these drugs IF they have been approved by the FDA for other conditions in addition to the weight loss.  The conditions listed are specific.  Medicare will not pay for these drugs unless you have one of the specific conditions in your diagnosis.  

Look at the table at this link:

ASPE.hhs.gov - 11/26/2024 - Medicare Coverage of Anti-Obesity Medications )

You must have a diagnosis of Type2 Diabetes Mellitus and be over weight by a certain BMI for 

Mounjaro (tirzepatide )

Ozempic (semaglutide)

Rybelsus (semaglutide)

Victozia   ( liraglutide)

You must have a diagnosis of a Cardiovascular Event and be over weight by a certain BMI for

Ozempic (semaglutide)

Victoza ( liraglutide)

Wegovy (semaglutide )

A cardio vascular event is described as a non-fatal myocardial infraction, or non-fatal stroke.

In just the last few months, Zepbound (tirzepatide) has been approved for obstructive sleep apnea.

[GailL1]

@SpringIsHereVA 

As of now - some are covered BUT NOT for weight loss - coverage is extended ONLY if they are prescribed for a medically accepted indication OTHER THAN weight loss.  For example, Wegovy (semaglutide) is now approved to reduce the risk of cardiovascular events in adults who are obese or overweight.

ASPE.gov - 11/24/2024 - Medicare Coverage of Anti-Obesity Medications  

As of August 2024, Ozempic, Mounjaro, Rybelsus, and Wegovy are covered Part D drugs for the treatment of type 2 diabetes and cardiovascular disease. 

Some of the others are not because they haven't been approved for anything other than weight loss and Medicare does not cover drugs just for weight loss.     

Some or maybe all of those that are approved maybe only available on an enhanced Part D plan - just check the formulary

Drug	Active Ingredient	Weight Reduction	Type 2 Diabetes  Mellitus*	Risk Reduction of CV  Events
Mounjaro	tirzepatide		X
Ozempic	semaglutide		X	X
Rybelsus	semaglutide		X
Saxenda	liraglutide	X
Victoza	liraglutide		X	X
Wegovy	semaglutide	X		X
Zepbound	tirzepatide	X

[maggie539]

  Thank you for this information.  Why when I look on my drug plan is it still over $600??   I can't afford that.  And the Patient assistant program from drug companies, don't honor reduced prices if you have medicare or medicaid 😞

[GailL1]

@maggie539 

I don’t know what the prices are on any of the plans but if that is your copay - that’s the copay - they are really expensive meds.  Medicare Part D plans do now have to offer a payment plan - you work the details out with your plan sponsor.  

Plus there is now a $ 2000 out of pocket limit for meds that are on your formulary then nothing else for the rest of the year.  

You should talk to your doctor - about your eligibility for the drugs ( your diagnosis) and then go from there.