Ozempic, a drugs used to deal with Type 2 diabetes, has gone viral as a weight reduction drug.
The #ozempic hashtag has over a billion views on TikTok, and extra individuals are looking out the net for Ozempic than for insulin, Viagra or Tylenol, in response to Google Trends knowledge for May 2023.
Medicare beneficiaries within the drug may be stunned to see that it’s typically coated by Medicare Part D. It’s one of many prescribed drugs on which Medicare, the federal well being care program for individuals age 65 and older and for youthful individuals with sure disabilities, spends probably the most cash every year.
But Medicare doesn’t cowl Ozempic for weight reduction — just for diabetes. Nor does Medicare cowl Wegovy, a weight reduction drug that makes use of the identical energetic ingredient as Ozempic.
In reality, Medicare doesn’t cowl any prescribed drugs for weight reduction. And due to authorized boundaries and price considerations, which may not change any time quickly.
Here’s what to find out about Medicare protection of Ozempic and different weight reduction medicine.
What is Ozempic?
Ozempic is a model identify for semaglutide, a prescription remedy manufactured and offered by Novo Nordisk. As an injection, it will possibly assist management blood sugar in individuals with Type 2 diabetes.
The Food and Drug Administration authorised Ozempic to deal with Type 2 diabetes in December 2017. Currently, there isn’t a generic model of the drug, and there may not be for a while — Novo Nordisk’s Ozempic patents expire as late as December 2031, in response to knowledge from the FDA.
In June 2021, the FDA authorised a semaglutide product for an additional objective: weight reduction. Novo Nordisk sells semaglutide for weight reduction underneath the model identify, Wegovy.
Medicare covers Ozempic for Type 2 diabetes
Medicare prescription drug plans would possibly cowl Ozempic, however solely to deal with diabetes. In 2021, Medicare spent over $2.6 billion to cowl Ozempic prescriptions. Because it’s an outpatient prescription drug, Ozempic falls underneath Medicare Part D. Original Medicare (Part A and/or Part B) gained’t cowl it.
Ozempic is No. 10 for the best whole Medicare Part D spending in 2021, in response to knowledge from the Centers for Medicare & Medicaid Services (CMS). About 459,000 Medicare beneficiaries have been coated for Ozempic in 2021, in response to CMS knowledge.
If you’ve Original Medicare, you should purchase a stand-alone Medicare Part D plan to get prescription drug protection. If you’ve Medicare Advantage, most plans embrace prescription drug protection. With Medicare Advantage, you can not purchase a separate Part D plan.
You’ll have to examine your plan’s formulary to substantiate if and the way the plan covers Ozempic.
Medicare doesn’t cowl Ozempic (or Wegovy) for weight reduction
Over 40% of U.S. adults age 60 and older are thought of overweight, in response to 2017-2020 knowledge from the Centers for Disease Control and Prevention.
Despite the prevalence of weight problems amongst older adults, Medicare gained’t cowl weight reduction medicine, together with Wegovy. Medicare Part D plans are prohibited from masking medicine “used for anorexia, weight loss or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity)),” in response to the Medicare Prescription Drug Benefit Manual.
That means until you’ve one other supply of protection, you’d have to pay out of pocket for a semaglutide prescription for weight reduction, whether or not it’s branded Ozempic or Wegovy.
What you’d pay out of pocket for Ozempic or Wegovy
Novo Nordisk’s record value for Ozempic is $935.77 per 4 weekly doses. For a full yr, that might be almost $12,200.
The record value for Wegovy is $1,349.02 per 4 weekly doses. For a full yr, that might be barely greater than $17,500.
Because Ozempic and Wegovy are nonetheless underneath patent safety, there’s no choice to purchase a less expensive generic model.
Covering weight reduction medicine can be expensive for Medicare
Policy change can be required for Medicare to start out masking weight reduction medicine. Legislation to permit protection has been launched in every of the previous six congressional phrases however by no means handed.
The excessive prices of weight reduction medicine may be one barrier to vary. For instance, if 10% of Medicare beneficiaries with weight problems took Wegovy, it will value Medicare Part D about $26.8 billion per yr, in response to estimates printed by researchers on the Vanderbilt University School of Medicine and the University of Chicago Department of Medicine within the New England Journal of Medicine in March 2023.
For reference, the prescription drug with the best whole Medicare Part D spending is Eliquis, an anti-stroke drug. Total Medicare Part D spending for Eliquis was almost $12.6 billion in 2021, in response to the latest annual knowledge out there from CMS.
The estimated $26.8 billion to cowl Wegovy can be greater than twice that quantity, or about one-eighth of the roughly $216 billion spent for all coated Medicare Part D medicine in 2021.
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Alex Rosenberg writes for NerdWallet. Email: [email protected]. Twitter: @AlexPRosenberg.
Source: www.bostonherald.com”