If you’ve been prescribed Ozempic to treat your diabetes, you likely know that prices can be costly. Government-funded programs like Medicare help cover the costs of many prescription medications, but whether it covers Ozempic is a bit tricky. This blog post will cover an overview of Ozempic and its Medicare coverage explanation, as well as some other diabetes treatment tools that Medicare helps cover.
Overview of Ozempic
What is Ozempic?
Ozempic (semaglutide) is an FDA-approved injectable prescription medication for the improvement of blood sugar levels of adults with type 2 diabetes [1]. Its active ingredient, semaglutide, helps the body respond to rises in blood sugar and makes the pancreas produce more insulin at these times. Simultaneously, it prevents your liver from releasing too much sugar [2]. Although this drug is FDA-approved and has helped many individuals with their type 2 diabetes, it also has several limitations. Serious side effects and allergic reactions may occur, so you must first consult with your healthcare provider to determine if Ozempic is right for you.
Ozempic and Pre-Diabetes
As previously mentioned, Ozempic is approved for type 2 diabetes. However, there is an “off-label” use of Ozempic for prediabetes, or elevated blood sugar levels that haven’t yet met the threshold of type 2 diabetes [3]. “Off-label” refers to a medication being prescribed for a condition the FDA has not formally approved it for [4]. Although it is typically not recommended to prescribe a drug to treat a condition other than what it is formally approved for, some physicians have prescribed Ozempic for prediabetes. This is because of current research that has found that other glucagon-like peptide-1 (GLP-1) medications helped people with prediabetes lower their blood sugar levels enough to prevent type 2 diabetes [5].
Despite this research, the FDA raises concerns about prescribing “off-label” GLP-1 medications for prediabetes. This is because using drugs unapproved for specific uses means that these drugs have not been carefully reviewed for efficacy and safety, which can lead to significant risks [6].
Medicare Coverage for Ozempic
Medicare Part D Coverage
Medicare Part D plans cover the costs of many prescription medications, and for 94% of plans, Ozempic is included. However, the amount of coverage you receive depends on which coverage stage you are in. If you are still in the deductible stage, meaning you haven’t yet met your deductible minimum payment, Ozempic will likely cost more than if you are in the post-deductible stage [7]. Additionally, Ozempic is often classified as a Tier 3 or Tier 4 medication, which means that it is a brand-name drug and often has a higher copayment than Tier 1 and 2 drugs [8]. Tier classification and copayment will vary based on a plan’s specific formulary.
Coverage Restrictions
It is important to note that Medicare coverage of Ozempic comes with a few restrictions. First, at this point, Medicare covers Ozempic for its FDA-approved purpose only: the management of type 2 diabetes. Medicare is not permitted by law to cover drugs for weight loss [9], though this may change in the future depending on policy changes. Additionally, Medicare requires most drugs to have prior authorization, meaning that your prescriber must contact your insurance plan and confirm that the prescription is necessary before you can receive coverage [10].
Medicare Diabetic Testing Guidelines
Comprehensive Diabetes Monitoring
Blood sugar monitoring is crucial for the management of diabetes. If you were advised to take insulin for your diabetes, your doctor will likely also recommend a continuous glucose monitor or CGM. This device gives you real-time updates about your blood sugar levels [11]. You should typically test and record your blood sugar levels at multiple times of the day—before meals and before you go to sleep [12]. You may need to test your levels extra when you are sick or have changes in your diet or exercise routine. Medicare Part B covers certain diagnostic procedures for type 2 diabetes. If your doctor deems you “at risk” for diabetes and recommends that you get a blood glucose laboratory screening test, your Medicare plan can help cover these tests based on your plan’s Part B coverage limits. It is important that you listen to your doctor’s recommendations for screening tests—these can help prevent diabetes before it’s formally diagnosed, and keep you up to date on your current health needs.
Preventive Measures [14]
Medicare cares about preventing diabetes in every way possible. This is why they put forth the Medicare Diabetes Prevention Program (MDPP), which is a health behavior change program designed to help you make the lifestyle changes necessary to reduce your chances of developing diabetes. In this program, you’ll learn how to make life-altering changes to your diet and exercise patterns, tips for controlling your weight, a designated coach to help you through these changes, and a group of people who are going through something similar who you can turn to for support. The program begins with 16-week sessions on these topics and also includes 6-month follow-up sessions to track your progress. According to the Centers for Disease Control and Prevention (CDC), these programs can help reduce your risk of developing type 2 diabetes by over 70% [15].
Diabetic Supplies Covered by Medicare Part B
Comprehensive Supply Coverage [16]
Medicare Part B covers blood glucose self-testing equipment (such as a CGM), insulin pumps as well as the insulin itself, and therapeutic shoes and shoe inserts. If you use insulin, Medicare will cover up to 300 test strips and 300 lancets every 3 months, and 1 lancet device every 6 months. If you do not use insulin, Medicare will cover up to 100 test strips and 100 lancets every 3 months, as well as 1 lancet device every 6 months. Blood glucose self-testing equipment will only be covered after the patient receives a prescription from their doctor claiming this is necessary. These supplies will not automatically be sent to the patient—the patient must first request them. It’s important to note that beneficiaries may have additional coverage and programs based on their specific plan.
Continuous Glucose Monitoring (CGM) Coverage
Medicare CGM Guidelines [17]
Many people with diabetes must regularly monitor their blood sugar levels with a CGM, or continuous glucose monitoring, device. The cost of this device can get pricey, which is why many benefit from Medicare coverage of CGM devices. Medicare helps cover the cost of CGM devices under a few conditions:
- You must be diagnosed with diabetes mellitus.
- You must take insulin or have a history of issues with low blood sugar
- You must receive a prescription for diabetes testing supplies and guidelines on how often you should test your blood sugar levels
- You must be trained on how to use a CGM device. If you have a caregiver, your caregiver must be trained on how to use this device.
- You must make regular appointments to visit your doctor in person or have Medicare-approved telehealth visits.
Additionally, not all CGM devices are approved to be covered by Medicare. The particular type of CGM device must be approved by your plan and the FDA to be covered [18].
Impact on Patient Care
Doctors often recommend continuous monitoring devices for diabetes for a reason—they help keep patients in the know regarding their blood sugar levels. These real-time updates can help patients make smart decisions about their diet, exercise patterns, and medications. Using a CGM device in combination with Ozempic treatment can help patients understand if their treatment is working properly, and if it may be causing any complications or side effects [19]. Above all, they keep patients in the know and aware of what is happening in their bodies, empowering them to take the front seat in managing their health.
Finding Medicare Suppliers for Diabetic Supplies
Navigating Supplier Networks [20]
If you prefer to order your medical equipment directly from a supplier instead of from the pharmacy, this can be done as long as the supplier is Medicare-approved or in your plans network. You’ll need a prescription from your doctor to order these supplies. To discover which medical equipment providers are approved by Medicare, visit the Supplier Directory, or your specific plan’s provider directory
Insurance Considerations
Diabetes medication and management tools may differ in coverage depending on your type of insurance. Research your specific plan to learn more about diabetes coverage.
Financial Considerations
Out-of-Pocket Costs
Medicare caps the monthly cost of insulin at $35 for those who qualify for Medicare coverage of diabetes management tools and medications [22]. This means that you will never pay more than $35 per month for covered and approved insulin, and you will not have to pay a deductible if your insulin is covered under the Medicare program.
Savings Opportunities
If you are looking to save money on diabetes management tools and medication, there are options out there for you. Unfortunately, Medicare cannot use manufacturer coupons to reduce the cost of diabetes medications [24], but there are other ways to save money. There are several state based and federal programs which help Medicare beneficiaries with prescription savings. Patients should research patient assistance programs to see if they qualify. These programs can end up saving patients a great deal of money on monthly prescription costs. Additionally, if you receive a 90-day supply of treatment, you’ll only pay $35 per month, meaning that your out-of-pocket maximum will be at most $105.
Potential Challenges and Solutions
Coverage Limitations
Coverage limitations and plan formularies may create roadblocks in your treatment journey. For an unlisted drug to be covered by Medicare, your doctor may need to provide a strong rationale for why this off-label drug is necessary, as opposed to other FDA-approved drugs, for it to be potentially covered. Navigating insurance complexities can feel confusing and isolating, which is why you shouldreach out to professionals for help in this space.
Alternative Approaches
Managing your diabetes using the interventions recommended by your doctor is highly recommended to ensure your health is maintained. However, there are ways to manage your diabetes without medication or supplies. Lifestyle interventions, like eating a healthier and more nutritious diet, exercising regularly, and getting enough quality sleep can help manage your diabetes [24]. It is important to still consult with your healthcare provider regularly while adjusting your lifestyle so you can check if these lifestyle changes are making a positive impact on your health.
Conclusion
As long as Ozempic has been prescribed by your doctor for the treatment of type 2 diabetes, Medicare currently covers the cost for the majority of plans. It is crucial that you closely follow your doctor’s instructions for taking care of your diabetes—everyone’s treatment journey is different. With ongoing research in diabetes management, we may see more evidence emerge about the effectiveness of certain medications. Contact Greater Good Health today with any questions about diabetes management, Medicare coverage, and alternative treatment options.