(Courtesy of Medicare Done) I could hear the frustration in her voice when she called. Susan had been hearing the buzz about new weight-loss drugs like Ozempic, Wegovy and Mounjaro for months. Stories of dramatic weight loss and renewed health had filled her social media feeds and news articles. After struggling with her weight for years and seeing friends achieve success with these medications, Susan decided it was time to explore her options.

With cautious optimism, Susan made an appointment with her doctor to discuss whether one of these medications could be right for her. She went into the appointment armed with information, ready to advocate for herself and her health.

However, to her disappointment, Susan’s doctor informed her that her Medicare Part D plan wouldn’t cover these weight-loss medications for her. Despite being FDA approved, the medications were not deemed medically necessary in Susan’s case.

What we discussed with Susan:

1. Diagnosis Requirements: Medicare Part D plans typically cover medications for weight loss only if they are prescribed for treating another medically accepted indication, such as Type 2 diabetes or cardiovascular conditions. If your friend’s condition warranted coverage under a different indication, that could explain why their claim was approved.
2. Formulary Differences: Each Medicare Part D plan has its own formulary, which is a list of drugs that the plan covers and their corresponding tiers. Weight-loss medications may be included on some formularies but not others depending on the plan’s coverage policies. Starting Oct. 15, Medicare Annual Enrollment, we can review and enroll in an alternative plan.
3. Prior Authorization: Many plans require prior authorization for weight-loss medications. This process involves your healthcare provider submitting additional information to justify the medical necessity of the medication. Without prior authorization, coverage may be denied.
4. Appeal the Decision: If you believe the denial was made in error or if you have additional information to support the need for the medication, you have the right to appeal the decision. Your doctor or pharmacist can help you through the appeals process.

Each situation is unique and seeking guidance from healthcare professionals and your Medicare broker can help clarify your options and improve your chances of securing coverage.

To schedule your 2025 annual review, email [email protected].

This article is for educational purposes only. Please consult with a doctor to determine if these drugs are suitable for you.