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Is Wegovy covered by Medicare?

It’s official, Medicare has approved the weight loss drug Wegovy to now be covered under Part D of Medicare with certain restrictions.

Weight management becomes increasingly challenging as we age, and for those navigating the golden years, effective solutions can seem elusive. However, the recent landmark approval of Wegovy, a revolutionary prescription weight loss medication, by Medicare has sparked a glimmer of hope for countless seniors nationwide. This comprehensive guide will enlighten you on the drug Wegovy, its Medicare approval, and how you or your loved ones might be eligible to benefit from this groundbreaking treatment.

Understanding Wegovy: A Beacon of Hope in Obesity Management

Wegovy, also known by its generic name Semaglutide, has emerged as a beacon of hope for individuals struggling with obesity. A sister to the widely acclaimed medication Ozempic, it has been found to induce significant weight loss, making it a groundbreaking advancement in the world of prescription weight loss drugs. Semaglutide, initially developed for diabetes management, demonstrated remarkable weight loss results during clinical trials, leading to its re-purposing and optimization for obesity treatment.

How Wegovy Works

Wegovy works by mimicking a hormone that regulates appetite, leading to a decreased craving for food. It also slows down the process of emptying the stomach, which contributes to a feeling of fullness. The combination of these effects has shown to result in notable weight loss for those participating in the studies.

The Road to Approval

On June 30, 2021, the U.S. Food and Drug Administration (FDA) granted approval for Wegovy as a chronic weight management treatment in adults with obesity or overweight with at least one weight-related condition. This decision marked a pivotal moment in the approach to obesity treatment, providing a pharmaceutical option that significantly augments traditional methods such as diet and exercise.  In March 2024 the U.S. Food and Drug Administration (FDA) approved an additional indication that Wegovy can be used to reduce the risk of major cardiovascular events such as death, heart attack, or stroke in adults with heart disease and obesity. This approval is what opened the door to Medicare now approving coverage for Wegovy.

Medicare’s Monumental Decision To Cover Wegovy

While this decision does not change current regulations barring Medicare from paying for obesity drugs, it does provide benefits for those who are obese and are at risk for a cardiovascular event.

What Medicare’s Approval Means for Seniors

Medicare’s endorsement of Wegovy gives seniors access to a potentially life-changing medication that was previously out of reach for many due to cost considerations. The coverage under Medicare Part D Prescription Drug plans significantly lowers the financial barrier, potentially expanding the reach of this therapy to those who could benefit most from it.

Eligibility Criteria and Cost Coverage

Here is where things get a bit murky.

To qualify for coverage under Medicare, individuals need to meet specific eligibility criteria.

• Medical Necessity – the treatment using Wegovy must be medically necessary due to cardiovascular disease.  Your physician must first deem it necessary as a suitable treatment.
• BMI Requirements – your Body Mass Index (BMI) must be classified as obese, and you are being treated for heart disease and/or at risk for stroke.
• Prior Authorization – some Medicare Part D prescription drug plans may require your physician to submit for prior authorization and provide supporting details on why you should qualify.

It is important to understand that Medicare did not approve Wegovy for weight loss.  If you are wanting to take Wegovy solely for weight loss, then you will be required to pay all costs.

Navigating Medicare Approval for Wegovy

Securing Medicare approval for a prescription drug can be a complex process, but with the right knowledge, it becomes a more navigable terrain. Here’s what you need to know to ensure the successful navigation of Medicare’s approval process for Wegovy.

Consulting Your Healthcare Provider

The first step is to consult with your healthcare provider to determine if Wegovy is a suitable option for your weight management goals. Your physician will assess your medical history and current health status to provide personalized advice and support in your decision to pursue Wegovy as part of your treatment plan.

Verify With Your Medicare Part D Plan

The reality is that not all Medicare Part D Prescription Drug plans are going to cover this expensive prescription.  Those that do may have varying costs associated with this particular drug, so it is important for you to know what kind of financial exposure you are opening yourself up to.

Recording Your Efforts

Consistent record keeping of your weight loss efforts is crucial for Medicare approval. Documentation of dietary changes, exercise regimens, and participation in weight management programs establishes a history of effort that fulfills Medicare’s stringent criteria for drug coverage.

Filing for Prior Authorization

For most Medicare drug plans, prior authorization is a prerequisite for coverage of Wegovy. This entails your healthcare provider submitting a request to Medicare, justifying the medical necessity and appropriateness of the medication for your particular case. Once approved, this step paves the way for access to Wegovy through your Medicare Part D plan.

The Impact of Wegovy on Senior Health

The introduction of Wegovy into the arsenal of treatments for seniors with obesity could have a profound impact on their health and quality of life. With obesity being a significant risk factor for many chronic diseases prevalent in the elderly population, the potential for substantial weight loss through Wegovy offers a pathway to better health outcomes. It is important to remember that Wegovy should be used in conjunction with a reduced calorie diet and exercise.

Frequently Asked Questions About Medicare’s Approval of Wegovy

Understanding the nuances of Medicare’s coverage of Wegovy can be fraught with questions. Here, we address some of the common queries that may arise for seniors and their caregivers.

Did Medicare Approve Wegovy for Weight Loss?

No.  Medicare is prohibited from covering weight-loss medications.  Medicare’s approval of Wegovy is based on the approval of the FDA’s expanded use of the drug to reduce the risk of heart attacks and strokes.  The bonus side effect is that it reduces appetite, which will help many folks lose weight.

Are Medicare Part D Plans Already Covering Wegovy?

No.  As of this time of this article, only the approval by The Centers for Medicare & Medicaid Services has taken place.  There is a chance that later in the year we could start seeing Part D plans begin to offer coverage for Wegovy.

Will Medicare Advantage Plans Cover Wegovy?

Maybe.  Once again when we talk about Medicare Part D coverage, this is provided both by stand-alone Part D Prescription plans (PDP) and thru Medicare Advantage plans that have a built-in prescription drug benefit (MAPD).  The Part D prescription component in a MAPD plan will have its own formulary list (just like a stand-alone PDP plan). 

How Do I Start the Process to Get Wegovy Covered Through Medicare?

The process typically begins with a discussion with your healthcare provider, followed by documentation of treatment for cardiovascular disease and a request for prior authorization from your Medicare drug plan after it has added Wegovy to its formulary list.

It is important to follow the recommendations of your healthcare provider. There are reasons why you hear all the medical disclosures (including side effects) during a prescription television commercial.

Will Medicare Cover the Full Cost of Wegovy?

The extent of coverage for Wegovy varies by Medicare Part D plan. Some plans may offer full coverage, while others may require a copayment or coinsurance.

Final Verdict of Wegovy Now Being Covered By Medicare

The approval of Wegovy by Medicare marks a significant step forward in the battle against obesity, for seniors who are at risk for cardiovascular events. By understanding the criteria for Medicare coverage and proactively engaging with the process, seniors can now possibly access a cutting-edge treatment that may transform their efforts in weight management.

While we all anxiously await to find out how many Part D plans will start covering Wegovy, take the time to find out if you are paying too much for your current Medicare insurance plan.

This article is for informational purposes only and is not intended to provide any medical advice.  All medical advice should be sought from your current healthcare provider.

Sources for Quoted Information

• Food and Drug Administration (FDA)
• Centers for Medicare & Medicaid Services (CMS)
• Novo Nordisk

Many folks think the Medicare Advantage Open Enrollment Period runs from October 15th – December 7th. This is actually incorrect. The term Open Enrollment has been thrown around over the years to somehow cover different enrollment periods. This is actually wrong! The dates listed above are actually for the Medicare Advantage Annual Election Period.

The Medicare Advantage Open Enrollment Period runs from January 1st – March 31st and limits the choices and changes that a Medicare beneficiary can make. During the Annual Election Period, those on Medicare have access to make changes to just about everything related to Medicare such as switching from one Medicare Advantage plan to another, switching their stand-alone Part D prescription drug plan, leaving original Medicare to enroll in a Medicare Advantage plan, or leaving a Medicare Advantage plan to go back to original Medicare.

What is the Medicare Advantage Open Enrollment Period?

The Medicare Advantage Open Enrollment Period starts on January 1st and ends on March 31st each year. During this period, you are allowed to make changes to your Medicare Advantage plan. This means you can switch from one Medicare Advantage plan to another or go back to Original Medicare.

Can I switch from original Medicare to a Medicare Advantage plan during the Open Enrollment Period?

No! Let’s say that you currently have original Medicare along with a stand-alone Part D prescription drug plan. In addition to this coverage you also have a Medicare Supplement Plan G. If you had wanted to make the change to a Medicare Advantage plan, you would have had to complete this during the Annual Enrollment Period (Oct 15th – Dec 7th).

Can I switch from a Medicare Advantage plan to original Medicare?

Yes! If you are enrolled in a Medicare Advantage plan and find that it simply is not working for your healthcare needs, then you can use this enrollment period to make a switch back to original Medicare. Keep in mind that you will need to enroll in a stand-alone Part D prescription drug plan so that you do not face any future penalties.

Is it a good idea to switch Medicare Advantage plans during Open Enrollment?

When deciding to switch from one Medicare Advantage plan to another, consider factors such as the participation of all your providers in the new plan’s network. If they do, then you need to determine what benefits do you gain by switching. Are your co-payments going to be lowered? Are you getting additional benefits in the new plan that are not available in your current plan? All of these items and more should be weighed before making a switch.

Should I switch from a Medicare Advantage plan back to original Medicare during the Open Enrollment Period?

While this is actually a common event that takes place, it is important to keep in mind several things. If you have always been on a Medicare Advantage plan for more than 12 months and decide to switch back to original Medicare and get a Medicare Supplement plan, you will need to qualify for the Medicare Supplement plan by answering a list of health questions. Qualifying for the Medicare Supplement plan is not a guarantee during the Medicare Advantage Open Enrollment period.

If you left original Medicare and a Medicare Supplement plan during the annual election period (and it is your first time enrolling in a Medicare Advantage plan), then you would be within your 12 month trial period where you could return back to original Medicare and have your existing Medicare Supplement issued with no health questions. You would also be able to sign up for a stand-alone Part D prescription drug plan.

Why are people leaving Medicare Advantage plans?

People commonly leave Medicare Advantage plans due to health status changes, network alterations such as providers no longer participating, or the requirement of prior authorization before consulting a specialist or undergoing a test. Another common reason that a beneficiary might leave a Medicare Advantage plan could be due to their prescription coverage offered within the plan. Such things as a certain prescription no longer being on the plan’s formulary or that same prescription now is a higher tier that requires the member to pay a higher amount out of pocket can have a negative impact.

What is the scandal about Medicare Advantage plans?

There are a couple of issues that have made Medicare Advantage plans look tarnished in recent years. The Centers for Medicare and Medicaid Services (CMS) have accused some Medicare Advantage plans of overcharging the government for medical services. This is simply a nice way of saying that they committed fraud.

Another issue is that complaints regarding Medicare Advantage plans increased dramatically over the last couple of years. Many folks who called into the 800#s they saw on television ads made switches into Medicare Advantage plans who didn’t completely understand the restrictions such as networks, referrals, and having to be responsible for co-pays and co-insurance out of their own pocket. According to CMS the amount of complaints rose from 16,000 in 2020 to nearly 40,000 in 2021.

New regulations have transformed the display of Medicare Advantage ads on TV, yet out-of-country rogue call centers continue to plague seniors. These call centers blatantly disregard the Federal Do Not Call List, cold call seniors multiple times a day with such bogus claims as:

• Saying they are with Medicare (CMS)
• Scammers falsely claim that a Medicare beneficiary’s current card is invalid and needs replacement with a new plastic card. Once the senior provides their Medicare ID to these callers, the scammers transfer them to a licensed US call center. Unbeknownst to the senior, the call center switches them into a Medicare Advantage plan without their knowledge or consent.

Is being enrolled in a Medicare Advantage plan the same as having a Medicare Supplement?

Absolutely NOT!! When it comes to Medicare, there are a lot of terms to keep straight. One question many people have is whether being enrolled in a Medicare Advantage plan is the same as having a Medicare Supplement, also known as Medigap. The short answer is no. While both types of plans can help cover costs that original Medicare doesn’t, they work in different ways. Private insurance companies offer Medicare Advantage plans, typically replacing original Medicare altogether. In contrast, Medicare Supplements actively fill in the gaps while working alongside original Medicare. It’s important to understand the differences between the two so you can choose the plan that’s right for you.

Is there a simple list of what I can and can’t do during the Medicare Advantage Open Enrollment Period?

Yes! Below is a list of everything you can do during the Open Enrollment Period.

• Change from one Medicare Advantage Plan to another Medicare Advantage Plan.
• Drop your current Medicare Advantage Plan and return to Original Medicare and get a stand-alone Medicare Part D prescription drug plan.
• Make a one-time-change

What you can’t do during the Open Enrollment Period

• Enroll in a Medicare Advantage plan for the first time.
• Switch your current stand-alone Part D prescription drug plan to another stand-alone Part D plan.
• Make changes more than once

Remember, the Medicare Advantage Open Enrollment Period doesn’t offer options to switch Medicare Supplement carriers without medical underwriting.

Conclusion

Review your current Medicare Advantage coverage during the Open Enrollment Period to ensure it meets your specific health care needs. If you are not sure, then you can simply contact Senior Benefit Services, Inc for a non-bias and free review. Give us a call today at (800)924-4727 or use the contact form below.

We would all love to hear that Medicare is free at age 65, but that is really not the case. Turning 65 is a significant milestone for many Americans. As you approach this milestone, you may be wondering about Medicare and how much it will cost you. There are many misconceptions about Medicare, but one of the most frequently asked questions is, “Do I have to pay for Medicare?” The answer is yes, but the amount you pay depends on your income, the type of Medicare coverage you choose, and when you enroll. This article will cover everything you need to know about paying for Medicare.

Is There A Monthly Fee To Have Medicare?

Yes, there is a monthly fee for Medicare Part B, which covers doctor visits, outpatient care, and medical equipment. In 2024, the standard monthly premium for Part B is $174.70. However, the amount you pay may be higher based on your income. If you have a high income, you may be subject to an Income-Related Monthly Adjustment Amount (IRMAA). If you are single and making above $103,000 or married filing jointly and making above $206,000 be sure to check out our IRMAA chart for additional premiums owed in 2024.

Is Medicare Free for US Citizens?

Medicare is not free for US citizens. While you may not have to pay a premium for Part A, which covers hospitalizations, Part B requires a monthly premium. Additionally, Medicare does not cover all expenses, and you may still be responsible for copayments, deductibles, and coinsurance.

Do You Have to Pay for Medicare at Age 65?

If you or your spouse paid Medicare taxes while working, you will be eligible for premium-free Part A when you turn 65. Now keep in mind that if you or your spouse happened to only work a part-time job for a year or so, that will not qualify you to receive premium-free Part A. To qualify for premium-free Medicare Part A you must have worked for 40+ quarters (10 years) and paid Medicare taxes. See the chart below for Part A monthly premium costs for 2024 below.

However, you will still need to pay a monthly premium for Part B. If you do not enroll in Part B when you are first eligible, you may be subject to a late enrollment penalty.

How Much Do I Have To Pay for Medicare When I Turn 65?

The amount you will pay for Medicare when you turn 65 depends on a few factors. If you or your spouse paid enough Medicare taxes while working, you will not have to pay a premium for Part A. The standard monthly premium for Part B in 2024 is going to be $174.70, but the amount you pay may be higher based on your income (IRMAA).

What Happens If You Don’t Enroll in Medicare Part A at 65?

If you are eligible for premium-free Part A and do not enroll in it when you turn 65, you may have to pay a penalty. The penalty is 10% of the Part A premium for every 12-month period you could have been enrolled but were not. The penalty lasts for twice the number of years you could have been enrolled but were not.

How Do You Pay for Medicare If You Are Not On Social Security Already?

If you are not receiving Social Security benefits when you become eligible for Medicare, you will need to pay your premiums directly. You can pay your Medicare premiums online, by mail, or by phone. If you are enrolled in Medicare Advantage, a Medicare Supplement or a Medicare prescription drug plan, you may have additional costs.

How Much Will Social Security Take Out For Medicare in 2024?

In 2023, the standard monthly premium for Part B is $1640.90. Social Security withholds this premium from your benefit payments each month. Social Security will withhold for Medicare in 2024, but it will be about 3.5% ($5.80) higher at $174.70 per month.

How Do You Qualify For Free Part B Premium?

Some people may qualify for free Part B from Medicare if they meet certain income and asset requirements. The program is called Extra Help, and it is available to people who have limited income and resources. You can apply for Extra Help online, by mail, or by phone.

Is Medicare Part B Giveback the Same As Free Part B?

No! Medicare Part B giveback is found in certain states/counties where the reimbursement rates from Medicare to the private insurance companies offering those plans is higher. Some plans will credit the full Part B premium back to you and others might only credit a portion of the Medicare Part B premiums back to you.

It is important to understand that these plans are not available everywhere. In addition, you would need to be enrolled in a Medicare Advantage plan and not original Medicare.

Are Medicare Advantage Plans Free?

No! This is a huge misconception that many folks have. While some Medicare Part C plans may be $0 premium each month, you must continue to pay your Part B monthly premium. It is also very important to understand that Medicare Advantage plans ‘share’ the costs with you. This means that you will have co-payments and co-insurance to pay out of your pocket for each service. Now the good news is that Medicare Advantage plans must have an annual maximum out of pocket that sets a yearly cap on how much you would have to pay out of pocket. Some plans may have a $3,000 maximum whereas others may have a maximum of $7,500.

Conclusion

Medicare can be confusing, and the cost is an important factor to consider when deciding which coverage to choose. While Medicare is not free, it provides essential coverage and protection against high medical costs. Understanding the costs and requirements of Medicare will help you make informed decisions and plan for your future. There is no need to go at this alone! Call Senior Benefit Services, Inc. today at (800)924-4727 to get the help you deserve.

Switching from a Medicare Advantage Plan back to Original Medicare might not be something you read about often, but it actually happens quite a bit. Medicare Advantage Plans have become increasingly popular among seniors over the years because of their affordability and additional benefits like vision, hearing, and dental coverage. However, some seniors may find themselves unsatisfied with their Medicare Advantage Plan or may want to switch back to Original Medicare. If you’re one of these seniors, you may be wondering if switching from a Medicare Advantage Plan back to Original Medicare is possible. This blog post will help answer your questions and guide you through the process.

When Can You Return Back to Original Medicare?

If you find yourself wondering if or when you can return back to original Medicare, it’s important to understand that there are specific times during the year when you can make changes to your Medicare coverage. The Annual Enrollment Period (AEP) runs from October 15th to December 7th each year, during which you can enroll in or switch your Medicare Advantage or prescription drug coverage. Additionally, if you’re already enrolled in a Medicare Advantage Plan, there is a separate enrollment period called the Medicare Advantage Open Enrollment Period (OEP) that runs from January 1st to March 31st each year. This period allows you to make changes to your Medicare Advantage Plan, including switching to a different Medicare Advantage Plan or switching back to Original Medicare. You can generally only switch outside these enrollment periods if you qualify for a Special Enrollment Period, which certain circumstances such as relocating to a new area may trigger.

Things To Consider When Leaving Your Medicare Advantage Plan

If you’re considering switching back to Original Medicare, it’s important to understand the differences between Original Medicare and Medicare Advantage. Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance), which are offered by the federal government. Medicare Advantage, on the other hand, is a private insurance option that covers the same services as Original Medicare, but may offer additional benefits like vision, hearing, and dental coverage. Original Medicare may have higher out-of-pocket costs, but it allows you the freedom to choose your own healthcare providers. Learn more about Medicare Supplement plans and stand-alone dental, vision, and hearing plans.

How To Switch From Your Medicare Advantage Plan back to Original Medicare?

To switch from a Medicare Advantage Plan back to Original Medicare, you’ll need to contact your Medicare Advantage Plan provider or call Medicare directly at 1 (800) MEDICARE. You can also enroll in a Part D prescription drug plan at this time if you’d like and it should automatically end the Medicare Advantage plan (as long as the plan has prescription drug coverage integrated into it). Once you’re back on Original Medicare, you’ll have the option to enroll in a Medicare Supplemental Insurance (Medigap) Plan, which can help cover your out-of-pocket costs like deductibles, coinsurance, and copayments. If you are switching out of a Medicare Advantage plan that has prescription drug coverage, you most definitely will want to enroll in a stand-alone Part D prescription plan.

Can I Get A Medicare Supplement Plan After Switching Back To Original Medicare?

If you decide to switch from a Medicare Advantage Plan back to Original Medicare and wish to enroll in a Medicare Supplemental Insurance plan, note that you might need to respond to health-related questions for eligibility. Keep in mind that if you turned 65 and initially enrolled into a Medicare Advantage plan and have been on that plan for less than 12 months then you can qualify for a special enrollment period (SEP). This SEP allows you to return to original Medicare and enroll in a Medicare Supplement plan with no underwriting. Your Trial Right is the name of this specific SEP. Learn more about other Special Enrollment Periods and how to qualify.

Final Thoughts

Switching from a Medicare Advantage Plan back to Original Medicare is possible, but it’s important to understand the enrollment periods and differences between the two options. If you’re thinking about making the switch, be sure to contact your Medicare Advantage Plan provider or call Medicare directly at 1 (800) MEDICARE. And if you decide to enroll in a Medigap plan, be sure to do so during your open enrollment period to ensure you get the best coverage and pricing. By understanding the process and timing, you can make an informed decision that best meets your healthcare needs and budget. If all of this still sounds confusing, then let one of our advisors help. Simply give us a call at (800)924-4727 and experience why Senior Benefit Services, Inc has so many satisfied clients. Remember, “We Make Medicare Easy!”