As retired Americans meet and learn the challenges of managing their weight, understanding the healthcare and medication options available becomes even more important.
Medicare, the federally run healthcare for individuals over 65 and some under 65 with qualifying disabilities, will likely be the main option for those wanting to find coverage for their weight loss management.
In this article, we’ll dive into Medicare’s coverage regarding weight loss management and medication, uncovering what is and isn’t covered. For those who may be new to Medicare and are interested on how to apply, and what weight management will look like, you can find a step by step guide here:
https://boomerbenefits.com/how-to-apply-for-medicare-a-step-by-step-guide/.
Different parts bring together Medicare. Part A covers your inpatient hospital room and board, consisting of a semi-private room, regular meals, and other services like certain lab services, skilled nursing, hospice, and home healthcare. Part B covers your outpatient services, like doctor visits, preventative visits, tests, and services, as well as durable medical equipment, like wheelchairs and diabetic monitoring supplies.
Part C is another term for Medicare Advantage plans. When you enroll in Part C, you are still required to stay enrolled in Parts A and B and pay the Part B premium. However, you’re opting to receive your coverage from a private company instead of Original Medicare Part A and B. These plans will also typically include your drug coverage, which brings us to Part D.
Medicare Part D is your prescription drug coverage. If you’re receiving your coverage from Original Medicare Parts and B, you’ll need to enroll in a stand-alone Part D Prescription Drug plan.
While Medicare typically covers medically necessary services and supplies, including prescription drugs, it doesn’t cover all available medications. Whether or not Medicare will cover a specific medication is based on many factors, such as whether the prescribed medication is deemed reasonable for treating a certain health condition.
Types of weight loss medications
There are numerous types of weight loss medications and different ways they target fat loss. Most people are familiar with appetite suppressants, medications that can help increase metabolism, and fat absorption inhibitors. Coverage under Medicare will depend on the different parts of Medicare and the reason why the weight loss medications are being prescribed.
Since Part A is inpatient coverage, you generally won’t see weight loss medications covered under this part, as these medications are typically prescribed in outpatient settings. Part B may cover certain medications administered by a provider in an outpatient setting, like a doctor’s office. Under Part C, medications used to help with weight loss will depend on that particular plan’s formulary and whether or not the Advantage plan offers additional coverage for weight loss medications that Original Medicare doesn’t typically cover. Part D is what you will generally find most medications covered under, including drugs that can assist with weight loss. However, coverage will depend on the plan’s formulary, which lists all covered medications.
Criteria for Medicare Coverage of Weight Loss Medications
When it comes to weight loss medications, Medicare will only cover these medications if they are reasonable and necessary for treating a certain medical condition and not solely for the reason of weight loss.
For example, if someone were prescribed Ozempic for weight loss, they’d likely need to meet certain criteria, like using the Ozempic for another medical condition, such as diabetes. Eligibility can also depend on certain drug coverage restrictions put in place by a plan’s Part D coverage.
Some plans require prior authorizations, step therapy, or quantity limits that can prevent an individual from receiving coverage for their medication. Doctor recommendations and their documentation can play a significant role in the determination process.
Alternatives to Medicare Coverage
Medicare-aged Individuals who’ve realized they won’t be able to get their weight loss medication approved by Medicare may want to look into other avenues for coverage, such as patient assistance programs, coupon services, or international pharmacies. Patient assistance programs may require you to be diagnosed with certain health conditions for you to qualify. However, they’ve proven to provide significant financial savings when it comes to buying weight loss medications.
In closing
For individuals nearing or already on Medicare, understanding Medicare’s coverage is very important for familiarizing themselves with the different options for getting medication coverage. In early 2024, Medicare announced they would start to cover weight loss medications that were prescribed for lowering the risk of heart attack, stroke, or cardiovascular condition.
This is a great starting point to hopefully expand into the coverage of medications that are strictly for weight loss or management. By understanding Medicare’s coverage, nuances, restrictions, and cost alternatives, beneficiaries will be better suited to manage the cost and coverage of their weight loss medications.
