About 30% of people 65 and older in the U.S. have obesity, and there are many more eager to lose weight. Does Medicare cover treatments and medication to help them?
Heres what you need to know about Medicare coverage for prescription drugs taken for weight loss, including ones like Ozempic that arent approved by the Food and Drug Administration (FDA) for that purpose.
Medicare and weight loss treatments and medication
Medicare isnt allowed to cover drugs taken for weight loss because the 20-year-old Medicare Modernization Act specifically excludes them (as well as drugs for erectile dysfunction and a few other types).
The exclusion was put in partly because of the dangers certain weight loss drugs such as Fen-Phen had posed, leading to their being taken off the market due to potentially fatal hypertension and heart valve problems.
Medicare does cover weight loss counseling and certain types of bariatric surgery for some people 65 and older who have obesity.
Medicare covers Ozempic and Mounjaro as Part D medications when prescribed to treat diabetes because the FDA approved them for this purpose. The thing is: These expensive drugs (about $16,000 annually for Ozempic and over $13,000 for Mounjaro) have also been proven to lead to weight loss for some users.
The commercials say, Even though this is not for weight loss, you may lose weight, says Diane Omdahl, author of Medicare for You and CEO of the Medicare advisory firm 65 Incorporated.
Many employer health plans and private health insurers, however, wont pay for drugs like Ozempic when used for weight loss. The Wall Street Journal notes that fewer than a quarter of employer plans cover any drug specifically for losing weight.
Wegovy, which is the same drug as Ozempic, also from manufacturer, Novo Nordisk, is FDA-approved for weight loss. The manufacturer of Mounjaro, Eli Lilly, expects FDA approval for weight loss as early as the end of the year.
There are only two ways Medicare could cover these types of drugs for weight loss, says Tricia Neuman, senior vice president of the health policy research and news organization KFF and executive director of its Program on Medicare Policy.
One avenue is for Congress to change the law, she says. Theres currently pressure by some drug manufacturers to make that happen.
Another [way Medicare might cover weight-loss drugs] is for some kind of demonstration project from the Biden administration to see whether drugs prescribed for weight-loss have other beneficial effects, such as lowering cholesterol or helping with heart disease, and whether that in turn produces long-term savings, notes Neuman.
She hasnt heard anything publicly or privately from the administration about launching such a project, though.
If 10% of Medicare beneficiaries with obesity use Wegovy, the annual cost to Medicare could be $13.6 billion to $26.8 billion, according to The New England Journal of Medicine. Total annual Part D spending for Medicare is about $98 billion.
Its also possible that pharmaceutical companies could lower the prices of these types of drugs to make them more affordable for people if Medicare wont pay for them.