In 2021, Medicare spent $2.6 billion on Ozempic, making it one of the top 10 drugs that Medicare spends the most on (AARP).

What is Ozempic?

Ozempic, known as semaglutide, is purposed to control blood sugar levels with type 2 diabetes. It is injectable and has weight loss effects due to the activation of insulin. It is Food and Drug Administration (FDA) approved for those with type 2 diabetes, but not weight loss.

Eligibility and Pricing:

According to Good Rx, an American Healthcare Company that tracks prescription drug prices, 93% of Medicare prescription drug plans cover Ozempic under the condition that those eligible have type 2 diabetes.3

(The payments for the drug cost will vary based on the plan)

4 Without qualifying for type 2 diabetes, costs for this drug can vary from $900-1,100. (good rx).

There are restrictions even for those who qualify, including having limits on quantity for a refill, and those candidates must seek prior authorization from their prescriber before they start the drug.

Controversy with Ozempic:

According to the Centers for Disease Control and Prevention (CDC), over 40% of U.S. adults are medically obese in the United States. Many have flocked to the drug for results as a substitute for diet or going to the gym (CDC).

Ozempic can be a crucial drug for those with higher blood sugar levels as it can diminish the chance of heart disease and stroke. However, patients without type 2 diabetes or normal blood sugar levels should consult with their doctor before taking the drug. Side effects can lead to kidney disease, changes in vision, gallbladder problems, and inflammation of the pancreas.

Another issue with using it for "off-label" causes is that it creates a shortage of the drug for people who need it to control their diabetes.

Even though Medicare will not cover Ozempic for weight loss, plans can cover weight-loss counseling and weight-loss surgery, typically for people with a Body Mass Index (BMI) of 30 or higher (AARP).

Sources:

https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-ozempic-weight-loss-drugs.html#:~:text=Medicare%20doesn't%20cover%20drugs,for%20diabetes%2C%20not%20for%20obesity.

https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014

https://www.goodrx.com/conditions/weight-loss/does-medicare-cover-weight-loss-medication

https://www.cdc.gov/obesity/data/adult.html

https://aarp.org/health/medicare-qa-tool/does-medicare-cover-ozempic-weight-loss-drugs.html#:~:text=Even%20though%20Medicare%20Part%20D,BMI%20of%2030%20or%20higher.