Evidence is mounting that drugs such as Ozempic, Wegovy, and Mounjaro can offer numerous benefits to the millions of Americans suffering from obesity and its comorbidities. Originally developed to treat Type 2 diabetes, these drugs have exploded in popularity due to their ability to reduce weight, and American demand for these drugs is rapidly increasing.

Medicare Benefits

At an average annual cost of $10,000 to $15,000, such drugs are largely inaccessible to the populations reliant on Medicare, including seniors and those who are disabled and/or chronically ill. While health considerations have led to a push for expanded coverage of such drugs, outdated attitudes towards weight loss and weight gain still impact Medicare beneficiaries. However, although Medicare is forbidden to cover drugs when they are prescribed solely for their ability to reduce weight, Medicare can cover the drugs when they are prescribed to treat certain conditions that may be associated with excess weight.

Weight Loss Drugs

While drugs such as Ozempic and Wegovy are often lumped together as “weight loss drugs,” these medications are not chemically the same and don’t work identically on the body.

• Ozempic, Wegovy, and Rybelsus are semaglutide drugs, part of a class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists, or “single-agonist” drugs. They stimulate hormones that help control blood sugar levels and reduce appetite, leading to weight loss.
• Zepbound and Mounjaro are tirzepatide drugs, which are are GLP-1/GIP receptor agonists, or “dual-agonist” drugs. Dual-agonist drugs activate more than one hormone pathway, potentially leading to increased weight loss over medications that activate one hormone pathway.
• Other GLP-1 drugs, including liraglutide (Saxenda, Victoza) and dulaglutide (Trulicity) are now available as well.

The drugs also have different manufacturers and are prescribed to treat different conditions. The Food and Drug Administration (FDA) has, for example, approved Ozempic for the treatment of diabetes and to lower the risk of cardiovascular problems. Wegovy is approved for weight management and to reduce the risk of heart attack and stroke in obese and overweight adults. Zepbound is approved exclusively for chronic weight management.

What is considered “weight loss”?

Weight loss varies depending on the GLP-1 one uses and the dose. Clinical studies have shown that patients can lose 15 percent to 24 percent of their body weight. In addition to weight loss, these drugs have been shown to protect against cardiovascular disease and other conditions related to excess weight, such as diabetes, high blood pressure, and high cholesterol.

The rate of obesity among adults 60 and older has risen in the past decade, from 39.7 percent in 2010 to 41.5 percent in 2020, and this age cohort has the country’s second-highest overall obesity rate. Despite this, less than 1 percent of Medicare-aged patients who are overweight or obese, but don’t have Type 2 diabetes, are prescribed GLP-1 treatments.

This is directly a result of outdated attitudes to weight loss and weight gain, which were the norm prior to both the Department of Health and Human Services and the American Medical Association recognizing obesity as a complex disease involving a number of factors, including genetics. Though their long-term effects are still being studied, current evidence suggests that GLP-1 drugs offer clear clinical benefits to those with excess weight, with mild side effects and few risks.

Though it hasn’t happened yet, change appears to be on the horizon when it comes to Medicare’s coverage of weight loss drugs. Health care experts, politicians, and ordinary Americans are expressing increasing support for overturning an outdated Medicare policy that prohibits weight loss drug coverage, and CMS appears to be inching closer to permitting Medicare coverage of weight loss drugs.

In the meantime, if you have questions about Medicare coverage, please do not hesitate to contact our office at 1 (800) 680-1717. We look forward to the opportunity to work with you.