Weight Loss Drugs & Medicare

It can be very frustrating when medications you take are not covered by Medicare Part D plans. One of the hardest categories to deal with on Medicare lately is weight loss drugs.

The Social Security Act spells out the rules for coverage of medications and excludes certain categories from coverage under Medicare, including “weight loss (even if used for a non-cosmetic purpose (i.e., morbid obesity).”

Medications that can be covered under Medicare Part D drug plans are approved by the FDA for medical reasons other than weight loss, such as diabetes or cardiovascular risk, which include Wegovy, Ozempic and Mounjarno. 

Medications approved by the FDA for purposes other than weight loss can be covered by Part D drug plans but that does not guarantee that these medications will be included in a drug plan’s formulary. (A formulary is a list of medication covered by a specific Part D plan.)

• According to Medicare rules, Medicare Part D plans must include "substantially all" drugs in six protected categories and classes. (No clear definition of what "substantially all" actually means.)
  • Anticonvulsants: Drugs to treat seizures and other seizure disorders. 
  • Antidepressants: Medications for depression and other mental health conditions. 
  • Antineoplastics: Cancer medications. 
  • Antipsychotics: Drugs for mental illnesses such as schizophrenia. 
  • Antiretrovirals: Medications used to treat HIV/AIDS. 
  • Immunosuppressants: Drugs to prevent organ transplant rejection.
    
    
• Outside of those six protected categories and classes, the rule is that Medicare Part D plans must cover at least two drugs in the most commonly prescribed categories and classes.
  • At least two drugs can mean just two drugs
  • The most commonly prescribed categories and classes does NOT mean all categories and classes.

Medicare Part D plans may not cover any medications in the categories and classes not considered to be the most commonly prescribed.

GLP-1 generics, Zepbound, Saxenda and other medications simply for weight loss are not covered by Medicare and any Part D drug plan.

Check these links for additional information. 

• Medicare Part D Coverage Of Wegovy: Three Stumbling Blocks—https://www.forbes.com/sites/dianeomdahl/2024/08/06/medicare-part-d-coverage-of-wegovy-three-stumbling-blocks/
• Proposed Coverage of Anti-Obesity Drugs—https://www.kff.org/policy-watch/proposed-coverage-of-anti-obesity-drugs-in-medicare-and-medicaid-would-expand-access-to-millions-of-people-with-obesity/

Alternative Methods for Obtaining Weight Loss Drugs

*Formulary Exceptions For Drugs Not Covered by Part D Plans

In the middle of a plan year, if you need a medication that your drug plan does not cover, your physician can request a Formulary Exception.

This would allow you to:

• Obtain a Part D drug that is not included on a plan sponsor’s formulary, *OR*
• Obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit).

The physician’s supporting statement must indicate that the non-formulary drug is necessary for treating a condition because all covered Part D drugs would not be as effective or would have adverse effects.

If the plan sponsor denies the request, there is an appeal process. 

Check these links for more information:

• Medicare prescription drug coverage appeals — https://medicare-links.com/formulary-exception
• Coverage exceptions, CMS — https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions