This article is based on reporting that features expert sources.
As the overall population ages, there is a growing prevalence of diabetes among adults ages 65 and older.
In fact, an estimated 16.5 million 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 to treat diabetes and how to better reduce 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?
One of the newer classes of diabetes medications are called glucagon-like peptide-1 (GLP-1) receptor agonists.
Ozempic, chemically known as semaglutide, is the leading GLP-1 receptor agonist and works by mimicking the naturally occurring hormone GLP-1 released by the body in the stomach in response to eating. 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 feelings of 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 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, president-elect of the Obesity Medicine Association.
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.
Does Medicare Cover Ozempic?
Many people have questions about whether GLP-1 receptor agonists can help them and what does Medicare cover?
Original Medicare covers a portion of hospitalization costs under Part A and covers doctor’s bills and medical expenses under Part B. However, Original Medicare 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 for Type 2 diabetes, if deemed medically necessary by a doctor. To determine if Ozempic is covered by your specific Medicare Part D or Medicare Advantage plan, 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 3 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.
How Much Does Ozempic Cost Under Medicare plans?
The cost of Ozempic with Medicare prescription medication coverage (Part D) and Medicare Advantage varies depending on several factors, including:
- Your specific plan.
- Whether you have a standalone 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.
Does Medicare Cover Weight Loss Drugs?
Currently, Medicare cannot legally cover weight loss medications, but change may be on the horizon.
“Weight management is related to many chronic conditions, but a 2003 law prevents Medicare from covering drugs to treat obesity. This was initially because many weight loss drugs were not highly regarded, effective and – in some cases – were even dangerous,” Alexander says.
These weight loss medications not only treat obesity, but they also help treat certain chronic conditions and the many comorbidities, such as high blood pressure and high cholesterol.
A 2023 study published in the New England Journal of Medicine showed that Wegovy was superior to placebo in reducing the incidence of death from cardiovascular disease including heart attacks and strokes in people who have heart disease or are overweight.
According to the Centers for Disease Control and Prevention, approximately 40% of those enrolled in Medicare are obese. New legislation introduced last year with bi-partisan support, the Treat and Reduce Obesity Act, will allow Medicare to cover anti-obesity medications. 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.
“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.”
The two weight loss medications that have garnered the most interest recently are Wegovy and Zepbound. Zepbound (tirzepatide), originally approved as a diabetes medication called Mounjaro, was approved as a weight loss medication in November 2023. Until the Treatment and Reduce Obesity Act passes and Medicare is allowed to offer this new class of weight loss medications, it is too early to tell what the potential costs under Medicare will be.
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. Novo Nordisk’s (Ozempic and Wegovy) customer service is available at 1-844-Novo4Me (1-844-668-6463) or Eli Lilly’s (Mounjaro and Zepbound) can be found at 1-800-Lilly-Rx (1-800-545-5979) to find out further information.
Look online
Websites such as GoodRX or SingleCare are good places to start to help find the best retail 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. Be aware that counterfeit versions of Ozempic are available online. That means they could contain different ingredients or harmful ingredients. 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 (if you use it for the prescription or not), you may qualify for a manufacturer coupon, which can take the price down significantly. Sometimes to as little as $25 a month.
Patient assistance programs
Many drug companies have programs available to those who may benefit but cannot afford certain medications.
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 being considered 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 drug 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).
Bottom Line
Understanding coverage for medications like Ozempic is crucial, particularly for people living with diabetes.
While Original Medicare does not cover prescription drugs, Medicare Part D and some Medicare Advantage plans cover Ozempic for the treatment of Type 2 diabetes, when deemed medically necessary.
Although Medicare currently does not cover the cost of weight loss medications, proposed legislation may change this.
In the meantime, there are several ways to help with the high cost of medications, such as contacting the manufacturers for assistance, checking online retail prices, utilizing manufacturer coupons 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.