Did you know that more than 100 million Americans are obese, and more than 22 million Americans are severely obese. Being obese is expensive, as Obese people spend nearly $2,000 more in annual medical costs than people who are considered to be of a healthy weight, and people who are severely obese spend about $3,000 more than people who are deemed to be of a healthy weight. People are obese for many different reasons, whether it be conditions like diabetes, unhealthy eating habits, etc., and one way that we see people curb this issue is with the use of weight loss drugs like Ozempic.
Knowing these facts on obesity, those who are obese or severely obese must understand their insurance coverage due to some of these financial setbacks caused by obesity and the heavy costs of some of these weight loss drugs. A big question that may come up for seniors who are obese or severely obese is whether or not Medicare will cover these weight-loss drugs for them.
The key component in understanding whether or not Medicare will cover these drugs is understanding the different parts of Medicare, alongside which plan you have. Below is a quick summary of the parts of Medicare
- Part A: Medicare Part A, also known as hospital insurance, primarily covers inpatient care. This includes stays in a hospital where you are formally admitted, care in a skilled nursing facility following a qualifying hospital stay, hospice care for individuals with a terminal illness, and some limited home health care services. It is intended to help with services related to serious health events that require a stay in a medical facility or specialized end-of-life care.
- Part B: Medicare Part B covers outpatient medical services and preventive care. It includes doctor visits, outpatient procedures, lab work, diagnostic tests, imaging services like X-rays or MRIs, and certain types of home health care. Preventive services such as flu shots, annual wellness visits, and screenings for conditions like cancer and diabetes are also included. In addition, Part B provides coverage for mental health services, durable medical equipment (like walkers or wheelchairs), and ambulance transportation when medically necessary.
- Part C: Medicare Part C, commonly referred to as Medicare Advantage, is an alternative to Original Medicare (Parts A and B). These plans are offered by private insurance companies approved by Medicare. While they are required to provide at least the same coverage as Original Medicare, many Medicare Advantage plans include additional benefits not typically covered, such as prescription drugs, dental, vision, hearing, wellness programs, and gym memberships. These plans often use network-based models like HMOs or PPOs, which means members may need to use providers within the plan’s network.
- Part D: Medicare Part D provides coverage for prescription drugs. This part of Medicare is also offered through private insurance companies and helps to cover the cost of medications prescribed by a healthcare provider. Each Part D plan has a formulary, or list of covered drugs, which is organized in tiers that determine how much you pay for each medication. Coverage typically includes drugs for common conditions such as high blood pressure, diabetes, and high cholesterol, along with certain vaccines and specialty medications. Plans also include rules like prior authorization or step therapy for specific drugs.
Now that we know all the different parts of Medicare, it is important to understand that although weight loss surgery and behavior counseling would fall under Parts A and B, weight loss drugs wouldn’t, however, they could fall under Parts C and D. Knowing all of this is important as well so you can make the right decision when it comes to choosing your Medicare Plan.
The question now is, will Parts C and D cover your weight loss drugs, and the answer is maybe. Medicare covers FDA-approved medications for those with diabetes, heart conditions, or other conditions affecting weight gain. These include Mounjaro, Ozempic, Rybelsus, Victoza, and Trulicity, which are good for those who qualify. Some notable drugs not covered include Saxenda, Wegovy, and Zepbound. Any drug prescribed only for obesity or weight loss is excluded from Medicare coverage under current law. This puts those who aren’t diabetic, as well as weight loss drugs that are classified as cosmetic, in a tough spot.
While for some learning that they won’t be able to use Medicare to cover purchase of weight loss drugs may be a massive letdown, hopefully there can be some comfort taken in some alternatives that may be covered by Medicare, like weight loss surgery, behavioral counseling for obesity, diabetes management programs, and nutrition programs.
Another option for those struggling with the costs of weight loss drugs is the many different drug discount programs, like AARP, GoodRx, and WellRx. Seniors can also look into different drug manufacturer coupons to help them curb costs.
Ultimately, if and when you have questions, it is always best to look at your drug plan to see what benefits you have associated with your plan. If you have further questions, it is recommended that you speak to a doctor or a trusted Medicare advisor, such as Patricia Saint Louis, at 352-260-0202