Wegovy is now covered by 2024 Medicare drug plans.

Yes. However, although Wegovy® is now available as a Medicare Part D drug (based on certain health conditions, but not exclusively for weight loss), only a select number of 2024 Medicare drug plans are currently covering this newly-introduced drug.

Medicare Part D drug plans do not cover weight loss drugs, but...

On March 8, the FDA approved the Wegovy® injection “to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.” The FDA press release noted that Wegovy was the “first weight loss medication to also be approved to help prevent life-threatening cardiovascular events in adults with cardiovascular disease and either obesity or overweight”.

Although, prescription drugs that deal with “anorexia, weight loss, and weight gain” are statutorily excluded from Medicare Part D coverage, based on the FDA approval for additional medically accepted indications, the Centers for Medicare and Medicaid Services (CMS) released guidance about the Part D coverage of newly-released chronic weight management products or anti-obesity medications (AOMs). In their guidance, CMS noted that:

[i]f this same [otherwise-excluded Part D] drug also receives FDA approval to treat diabetes - or reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight, then it would be considered a Part D drug for those specific uses only.

Key Point: An Anti-obesity medication such as Wegovy would not receive Medicare Part D coverage for a beneficiary's weight management when this person did not also have the “additional medically accepted indication(s).”

The high cost of anti-obesity medications

Wegovy (and other anti-obesity drugs) are expensive in the United States*, with monthly retail costs around $1,500 and, as pointed out in an NBC News article entitled, "Will Medicare raise your monthly premiums to cover Wegovy?": “[Wegovy] needs to be taken lifelong to be effective, so we’re looking at potentially enormous lifelong costs.”

(* As noted by Morningstar, Wegovy costs about $1,349 a month in the United States "and the same drug costs just $140 a month in Germany and $92 a month in the United Kingdom".)

The high potential cost of covering an AOM like Wegovy was recently seen in North Carolina. As reported by USA Today, back in April, the North Carolina's health insurance program for state employees was forced to discontinued coverage of Wegovy and other AOMs because of the high cost to the health plan.

Over 23,000 members of the North Carolina health plan were using prescription weight loss drugs and the North Carolina "state treasurer projected the state's bill for the medication would soar to more than $1 billion over the next six years." In order to "continue to afford coverage of the drugs for weight loss, the state would have had to raise premiums to nearly $50 per month for about 750,000 employees and their dependents covered by the state health plan."

What does this mean for Medicare Part D beneficiaries?

Based on standard Medicare Part D coverage, a Medicare Part D plan beneficiary would have their total 2024 out-of-pocket costs for brand-name medications capped at about $3,333 (assuming the person is only using brand-name medications like Wegovy). In 2024, the total cost of Wegovy would then be shifted to the pharmaceutical company (paying 70% during the Donut Hole), the Medicare Part D plan, and the federal government. In 2025, a larger proportion of the potential cost of Wegovy will be shifted on to the Medicare Part D drug plan.

See: "Who actually pays for my Medicare Part D coverage?"

Accordingly, many people expect that Medicare Part D plans adding these anti-obesity medications to plan formulary will need to increase 2025 or 2026 plan premiums and to further control costs, plans will probably require some form of usage management restrictions, such as prior authorization, to ensure that the medications are being used by the plan member for an FDA “medically accepted indication”.

How many Medicare beneficiaries might be eligible to use Wegovy?

About 3.6 million people. According to research from the Kaiser Family Foundation (KFF), based on 2020 data, about 3.6 million Medicare beneficiaries (or 7% of beneficiaries) had established cardiovascular disease and obesity or overweight and could be eligible for Medicare coverage of Wegovy. The KFF researchers added that "[t]his number [of people eligible for Part D coverage of Wegovy] may well be higher based on more current data than were available for this analysis."

As a comparison, this estimated number of 7% of the Medicare beneficiaries who could be eligible for Wegovy use is more than 100 times higher than the number of people who used Wegovy on the North Carolina state employee health insurance program - where Wegovy users on the North Carolina state employee program represented only about 3% of all 750,000 insured.

What is Wegovy?

Wegovy (semaglutide) belongs to a class of drugs that are a glucagon-like peptide 1 receptor agonist (GLP-1). In effect, the medication reduces your apatite, gives you the sensation that you have had enough to eat or makes you feel fuller and reduces your desire for high-fat foods. These drugs were originally developed for the treatment of diabetes that also includes the drugs Novo Nordisk's Ozempic®, Eli Lilly's Mounjaro®, and Novo Nordisk's Rybelsus®.

How effective is Wegovy for reducing a person's weight?

Quite effective. According to a study funded by the pharmaceutical company that produces Wegovy (Novo Nordisk), "when Wegovy was used for 15 months with lifestyle support from a professional [counselor] to follow a calorie-reduced diet and to get more active, people lost on average 15% of their body weight."

How effective is Wegovy preventing an adverse cardiovascular event?

Significantly effective according to the FDA press release:

Wegovy’s efficacy and safety for this new indication [of prevent life-threatening cardiovascular events in adults with cardiovascular disease and either obesity or overweight] were studied in a multi-national, multi-center, placebo-controlled double-blind trial that randomly assigned over 17,600 participants to receive either Wegovy or placebo. Participants in both groups also received standard-of-care medical treatment (e.g., management of blood pressure and cholesterol) and healthy lifestyle counseling (including diet and physical activity). Wegovy significantly reduced the risk of major adverse cardiovascular events (cardiovascular death, heart attack and stroke), which occurred in 6.5% of participants who received Wegovy compared to 8% of participants who received placebo. [emphasis added]

Example 2024 Medicare Part D coverage of Wegovy

Using the this site the drug finder Drug Finder (viewing all Medicare drug plans in a specific area covering a single drug), we can see that Wegovy is covered by such plans as the 2024 UPMC for Life HMO Premier Rx (HMO) as a Tier 5 Specialty Drug with 33% cost-sharing (you pay 33% of the plan's negotiated retail cost, we are estimating at $1,300 to $1,500). The AOM has a Prior Authorization requirement and a 28 day Quantity Limit.

According to the June 2024 Medicare drug plan updates, Wegovy® is now available as a Medicare Part D drug (based on certain health conditions, but not exclusively for weight loss), only on 8 drug plan formularies which means only a select number (59) 2024 Medicare Advantage (MAPD) plans in various locations are currently covering this AOM.

The following is a list of MAPDs covering this medication based on the June 2024 formulary updates.
(Please note that it is possible that more Medicare drug plans have since included this medication on their plan's formulary).