Chronic weight management treatments and medications can be expensive, which is why having health care insurance coverage is a big help for many patients. However, before you sign up for a weight loss program or get a prescription for certain drugs like semaglutide, it’s important to check with your insurance provider if they're included in their benefits.
So can you get semaglutide for weight loss management under Medicare? Semaglutide is a relatively new medication approved for weight loss treatment. Original Medicare benefits currently don’t cover prescription medication for obesity or overweight. However, Medicare Part D and some Medicare Advantage plans may offer prescription drug coverage for any diabetes or weight loss medicine that the original plan doesn’t cover.
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Semaglutide is a GLP 1 receptor agonist approved as an anti-diabetic medication for patients with type 2 diabetes. Developed by Novo Nordisk, the drug works by mimicking the action of incretin hormones which are released by the digestive tract to help increase insulin production and regulate blood sugar.
It’s also shown promising benefits as an anti-obesity medication. Due to its mechanism of action, semaglutide can also help slow down the gastric emptying process which makes a patient feel fuller for longer periods of time. It helps suppress hunger and cravings so you’ll feel a lesser need to eat and eventually achieve weight loss.
As a weight loss medicine, semaglutide is usually administered subcutaneously or via injection. It can also be taken orally but this method is mostly prescribed for type 2 diabetes treatment. Some studies do show that oral semaglutide also has positive benefits for reducing body weight.
Unfortunately, taking semaglutide solely for obesity treatment or weight management isn't part of traditional Medicare coverage. One reason is that most insurance companies view weight loss drugs as lifestyle enhancers. Despite obesity being one of the major health concerns of many individuals, insurers believe that it’s more of a behavioral problem than a disease.
Semaglutide injections for weight loss can be prescribed for obese and overweight individuals provided that they have at least 1 established weight-related condition. This can include high blood pressure, high cholesterol, or type 2 diabetes. Some insurance coverage and healthcare provider may only cover semaglutide until you’ve developed a health condition.
But this shouldn’t discourage you from using your Medicare health insurance to address your obesity or overweight issue. There are several Medicare coverage plans and some of them may help cover your weight loss treatments and medication. Here are your common options for Medicare insurance coverage:
|Medicare Part A||Medicare Part B||Medicare Part D||Medicare Advantage|
|A health insurance plan that can covers costs for inpatient care in hospitals and also offers offers benefits for hospice care and home health care||This Medicare plan can help cover services that are medically necessary or preventative |
This can include inpatient and outpatient care for mental health, limited prescription drugs, screenings, and some medical equipment
This can include obesity screenings and counseling sessions to help improve your lifestyle and support your weight loss journey
|This offers prescription drug coverage for specific medications and can include recommended vaccines or shots |
You can have this coverage by getting it as an add-on to your existing health plan or joining a Medicare Advantage plan
|It's a health plan offered by private companies that are approved my Medicare |
It includes most benefits found in Medicare Plans A and B with additional coverage for services that the original plan doesn’t cover such as dental treatments and over-the-counter drugs for your health and wellness
Medicare Part B and Medicare Advantage plans are somewhat more lenient and offer insurance coverage for certain obesity treatments and weight control programs. Here are some of the benefits that these health plans offer:
Medicare Part B offers insurance coverage for preventive services, medical screenings, and behavioral counseling for obesity control. Patients who can get this benefit from this health plan are those with a body mass index of 30 or higher. The services should be administered by a physician, nurse practitioner, clinical nurse specialist, or licensed healthcare provider in a primary care setting.
Here are some of the intensive behavioral therapy services that Medicare can cover:
If your doctor advises you to meet with a dietician or nutritionist, it’ll already be an added expense and you'll have to pay for them out-of-pocket. Medicare may also cover scheduled meetings with your healthcare provider or physician for the following periods:
Along with dietary changes, weight loss can also be achieved with regular exercise. Fortunately, there are some Medicare plans that offer insurance coverage for gym memberships and other fitness programs. Medicare Advantage plans may be able to provide additional coverage for subscriptions to fitness services that can help in your weight loss efforts. Some of the common fitness benefits that you can get from the plans are:
Patients with severe obesity or a BMI of more than 35 can qualify for bariatric surgery covered by Medicare plans. This surgery can be considered medically necessary, especially for individuals with an underlying health-related condition like diabetes or cardiovascular disease. An insurance company can also cover this procedure if you’ve been unsuccessful with your weight loss efforts through diet and exercise or other medical programs.
Some of the types of bariatric surgery that Medicare plans can cover are:
Other weight loss procedures like liposuction is considered aesthetic by Medicare and isn’t included in its insurance coverage. They may also not cover other bariatric procedures like intestinal bypass, open sleeve gastrectomy, gastric balloon, and open adjustable gastric banding.
The only time that Medicare will offer to pay for semaglutide is if it’s prescribed for type 2 diabetes treatment. The medication is part of the select anti-diabetes drugs that are covered under Medicare Part D (prescription drug coverage). Here are other medications included in Medicare's preferred drug list:
Semaglutide may also fall under Medicare Part B if the medication was administered in an outpatient setting or doctor’s office. Likewise, if semaglutide was part of your treatment in a hospital or nursing facility, the provisions under Medicare Part A may apply.
There are different brands of semaglutide and the cost of the medication can differ depending on which product you buy. Here's a table comparing the prices of various semaglutide treatments:
|Form||Once weekly injection||Once daily oral medication||Once weekly injection|
|Dose||Comes in three different dosing strengths: 2 mg, 4 mg, and 8 mg||Also have three dosage options: 3 mg, 7 mg, and 14 mg||Typically come in 0.25 mg, 0.5 mg, 1m g,1.7 mg, and 2.4 mg|
|Estimated price||Ozempic can cost about $995 for 1 pre-filled injection pen with 1.5 mL of the solution||The price of Rybelsus can start at $949 for 30 oral tablets||Wegovy can cost about $1,430 for a 2mL solution|
Semaglutide is typically prescribed for long-term treatment of diabetes and weight management. Considering the prices, you can expect to spend around $10,000 or more for your annual supply of the medication. If your Medicare insurance plan doesn’t cover it, there are other options that can help you afford the treatment:
Novo Nordisk offers a savings card to eligible patients who have existing private or commercial insurance. You can pay as little as $10 per 30-, 60-, or 90-day supply of Rybelsus; a minimum of $25 for a 1-month prescription of Ozempic; and as little as $0 for a 28-day supply box of Wegovy. Check the manufacturer’s website to know more about the card’s eligibility requirements and restrictions.
Novo Nordisk also provides a patient assistance program (PAP) where they give free medication to patients who can't afford them or don’t have Medicare insurance. You can get Ozempic or Rybelsus at no cost as long as you qualify for the program.
You may also sign up for a Medicaid health plan, which is a joint federal and state program that offers insurance coverage to eligible individuals with limited income. Some states may include prescription drug coverage for semaglutide for weight management in their Medicaid insurance.
Semaglutide is a safe and effective treatment for type 2 diabetes and chronic weight management. However, this weight loss drug is typically not covered by most insurance companies. If you have a Medicare plan, talk with your insurance administrator to discuss if it's included in your coverage and check possible payment options.
Dr. V Medical Aesthetics is a reliable center that provides customized weight management plans with semaglutide medication. Our providers are well-experienced in offering medical advice on weight loss and diabetes disease control. Contact us to know more about our semaglutide treatments or book an initial consultation.
Dr. V Medical Aesthetics is ready to help you achieve your beauty goals. Contact us today to learn more about any of our services, and exactly what our team can do for you.