Medicare does not cover Wegovy, but some Medicare Advantage plans may cover similar medications
Original Medicare (Part A and Part B) does not pay for Wegovy, the brand-name injectable medication used for weight loss. However, some Medicare Advantage plans (Part C) do cover Wegovy or the generic version, semaglutide, though coverage rules and out-of-pocket costs vary widely by plan and by year.
Whether you can get Wegovy through Medicare depends on which type of Medicare you have, which plan you chose, and whether your doctor believes the medication is medically necessary for you. The cost difference between having coverage and paying out of pocket is substantial — Wegovy without insurance typically costs $900 to $1,350 per month.
Key Takeaways
- Original Medicare does not cover Wegovy or semaglutide for weight loss under any circumstances.
- Some Medicare Advantage plans cover Wegovy or semaglutide, but you must check your specific plan's formulary (drug list) to know whether yours does.
- Even plans that cover Wegovy may require prior authorization from your doctor, meaning your doctor must submit paperwork proving medical necessity before the plan will pay.
- If your Medicare Advantage plan does not cover Wegovy, you can switch to a different plan during the annual open enrollment period (October 15 to December 7) if coverage matters to you.
How Original Medicare handles weight-loss medications
Original Medicare Part D (prescription drug coverage) does not cover any medication prescribed solely for weight loss. This is a federal rule that applies to all beneficiaries. Wegovy, semaglutide (Ozempic when prescribed off-label for weight loss), tirzepatide (Zepbound or Mounjaro), and other GLP-1 receptor agonists fall into this category.
The reasoning is that Medicare classifies weight loss as a lifestyle issue rather than a disease state, even though obesity itself is now recognized as a chronic disease. This policy has not changed, though there is ongoing discussion in Congress about whether it should.
If you have Original Medicare and want Wegovy, you would pay the full retail price out of pocket, or you could look into patient information programs run by the manufacturer, Novo Nordisk. These programs sometimes reduce the cost for people who meet income requirements, but they are separate from Medicare.
What Medicare Advantage plans may cover
Medicare Advantage plans are run by private insurance companies and can set their own rules about which drugs they cover. Some plans do include Wegovy or semaglutide on their formulary, meaning they will help pay for it. Others do not.
Coverage is not may provide even if your plan lists the drug. Most plans that cover Wegovy require prior authorization, which means your doctor must submit a request to the plan explaining why you need the medication. The plan then decides whether to approve it based on criteria like your body mass index (BMI), whether you have weight-related health conditions (such as type 2 diabetes or heart disease), and whether you have tried other weight-loss approaches first.
If your plan does approve Wegovy, you will still pay a copay or coinsurance amount at the pharmacy. This is typically higher for brand-name drugs than for generics. Some plans place Wegovy in a higher cost tier, meaning you pay more out of pocket than you would for other medications.
How to find out what your plan covers
The only way to know whether your Medicare Advantage plan covers Wegovy is to check your plan's formulary. You can do this in three ways:
- Visit your plan's website and search the formulary (drug list) directly. Look for "Wegovy" or "semaglutide" and note any restrictions listed.
- Call the customer service number on the back of your Medicare Advantage card and ask whether Wegovy is covered and what the copay would be.
- Call 1-800-MEDICARE and ask a representative to look up your specific plan's coverage.
When you call or search, write down the exact copay amount, whether prior authorization is required, and whether there are quantity limits (some plans limit how many pens you can receive per month). This information can change year to year, so check again before your doctor writes a prescription.
Prior authorization and what your doctor needs to do
If your Medicare Advantage plan covers Wegovy but requires prior authorization, your doctor's office will need to submit paperwork to the plan before you can fill the prescription. This process typically takes 3 to 5 business days, though it can take longer if the plan asks for additional information.
Your doctor will need to document that you meet the plan's criteria. Most plans require at least one of the following: a BMI of 30 or higher, a BMI of 27 or higher with a weight-related condition, or a documented history of failed weight-loss attempts. Your doctor may also need to show that you have tried other approaches, such as diet and exercise, or other medications.
If the plan denies prior authorization, you have the right to appeal. Your doctor can submit additional information, or you can file a formal appeal with the plan. This process can take several weeks. If you believe the denial is unfair, you can also file a complaint with your state's insurance commissioner.
Switching plans if your current plan does not cover Wegovy
If your Medicare Advantage plan does not cover Wegovy and you want access to it, you can switch to a different plan during the annual open enrollment period. This runs from October 15 to December 7 each year, and any changes take effect on January 1.
Before you switch, compare plans carefully. Look at the formulary for each plan you are considering and confirm that Wegovy is covered and what the copay is. Also check whether your current doctor is in the new plan's network, because switching plans may mean changing doctors. Some plans have higher monthly premiums or higher deductibles, so weigh the cost of Wegovy coverage against the overall cost of the plan.
You can compare plans on Medicare.gov or call 1-800-MEDICARE for help. If you miss the open enrollment window, you generally cannot switch plans until the next year, unless you have a may have access to life event (such as moving out of your plan's service area).
Generic semaglutide and other options
Semaglutide became available as a generic medication in late 2023, which has made it less expensive for some people. However, Medicare Advantage plans do not automatically cover the generic version just because it exists. Some plans cover generic semaglutide but not brand-name Wegovy, some cover both, and some cover neither. Check your specific plan's formulary.
If neither Wegovy nor semaglutide is covered by your plan, ask your doctor whether other weight-loss medications might be. Some plans cover phentermine or other older weight-loss drugs, though these work differently and are not appropriate for everyone. Your doctor can help you understand which alternatives might work for your situation.
You can also ask about manufacturer information programs. Novo Nordisk (which makes Wegovy) and other drug makers sometimes offer discounts or free medication to people who meet income requirements, regardless of insurance status.
Frequently Asked Questions
Can I get Wegovy if I have Original Medicare and Part D?
No. Part D does not cover any medication prescribed for weight loss, including Wegovy. This is a federal rule that applies to all Original Medicare beneficiaries. If you have Original Medicare, you would need to pay out of pocket or look into manufacturer information programs.
What if my doctor says Wegovy is medically necessary for my diabetes?
Even if your doctor prescribes Wegovy to treat diabetes or another condition, Original Medicare still will not cover it for weight loss. However, some Medicare Advantage plans may cover it if your doctor documents that you have a weight-related condition and meet the plan's other criteria. Check your plan's formulary and ask your doctor to submit prior authorization if required.
Will my Medicare Advantage plan cover Wegovy next year if it does this year?
Not necessarily. Plans can change their formularies every year. Coverage that exists in 2024 may be dropped in 2025, or the copay may increase. Check your plan's formulary each year before your prescription is due to be refilled.
What happens if my prior authorization is denied?
You can appeal the decision. Your doctor can submit additional medical information, or you can file a formal appeal with the plan. If you disagree with the appeal outcome, you can file a complaint with your state's insurance commissioner or contact 1-800-MEDICARE for help.
Is there a cheaper way to get Wegovy if Medicare does not cover it?
Novo Nordisk offers a patient information program that may reduce the cost if you meet income requirements. GoodRx and similar discount programs also offer reduced prices at some pharmacies. Ask your pharmacist or doctor about these options, and compare prices before filling your prescription.