As of 2024, Medicare Part D may cover Wegovy if prescribed for obesity with a BMI ≥30 (or ≥27 with weight-related conditions), but coverage varies by plan. The Inflation Reduction Act now allows Medicare to negotiate weight-loss drug prices, potentially improving access. Out-of-pocket costs typically range from 10–50/month with coverage, but prior authorization is often required.
What Medicare Covers
Medicare provides health coverage for over 65 million Americans, but its drug benefits vary by plan. In 2024, 92% of Medicare Advantage (Part C) plans include prescription drug coverage, while stand-alone Part D plans cover about 1,500-4,000 different medications, depending on the formulary. However, weight-loss drugs like Wegovy (semaglutide) are not automatically covered—only 18% of Part D plans include it, and even then, strict prior authorization (PA) requirements apply.
Original Medicare (Parts A & B) does not cover Wegovy because it’s classified as a self-administered injectable drug, falling under Part D. The average monthly cost of Wegovy is 1,349 without insurance, but with Part D coverage, copays range from 10 to 450, depending on the plan’s tier placement and whether the deductible (545 in 2024) applies.
Key Medicare Coverage Rules for Wegovy
| Factor | Details |
|---|---|
| Coverage Type | Only under Part D or Medicare Advantage (Part C) with drug benefits. Original Medicare (Parts A/B) excludes it. |
| Formulary Inclusion | 18% of Part D plans (2024 data) include Wegovy, often as a Tier 3 or 4 drug. |
| Prior Authorization | 87% of plans require PA, proving BMI ≥30 (or ≥27 with weight-related conditions like diabetes). |
| Step Therapy | 42% of plans mandate trying cheaper alternatives (e.g., Saxenda) first. |
| Annual Cost (With Insurance) | 0–5,400 (after deductible; max out-of-pocket is $8,850 in 2024). |
| Manufacturer Savings | Novo Nordisk offers a $500/year coupon if covered by Medicare. |
Why Wegovy Coverage Is Limited
Medicare historically excluded weight-loss drugs due to cost concerns—adding Wegovy to all Part D plans could raise premiums by 13–25/month. However, since the FDA approved Wegovy for heart risk reduction in March 2024, some plans now cover it for cardiovascular patients (BMI ≥27 + heart disease).
For those without coverage, Medicare Supplement (Medigap) plans don’t help—they only pay Part A/B coinsurance, not drugs. The best alternative is switching to a Medicare Advantage plan with Wegovy in its formulary during Annual Enrollment (Oct 15–Dec 7).
Cost Breakdown: Wegovy on Medicare
- No Coverage: 1,349/month (16,188/year).
- With Part D (After Deductible): 450/month (5,400/year).
- With Manufacturer Coupon: 400/month (4,800/year).
- Low-Income Subsidy (LIS): Copays drop to 4.50–12 if eligible.
Wegovy Cost Details
Wegovy (semaglutide) is one of the most effective weight-loss medications available, but its price is a major hurdle for many patients. The list price is 1,349 per month, adding up to 16,188 per year without insurance. However, actual out-of-pocket costs vary widely—Medicare Part D beneficiaries may pay 10 to 450 per month, while those with commercial insurance often see 25 to 150 copays. Novo Nordisk, Wegovy’s manufacturer, offers a savings card that cuts costs by $500 per year, but it’s only usable if insurance covers at least part of the drug.
What Determines Your Wegovy Cost?
| Factor | Impact on Price |
|---|---|
| Insurance Coverage | Medicare Part D plans cover Wegovy in 18% of formularies, with copays ranging 10–450/month after the 545 deductible. Commercial insurers charge 25–$150/month if approved. |
| Prior Authorization (PA) | 87% of plans require PA, and denials are common—42% of patients must try cheaper alternatives (e.g., Saxenda) first. |
| Dosage Strength | Wegovy comes in 0.25mg, 0.5mg, 1mg, 1.7mg, and 2.4mg pens, but pricing is flat—all strengths cost $1,349/month at retail. |
| Pharmacy Choice | GoodRx reports 1,100–1,350/month at major chains (CVS, Walgreens), while Costco and Walmart sometimes offer 50–100 discounts. |
| Manufacturer Coupons | Novo Nordisk’s savings program reduces costs by $500/year, but Medicare patients can’t use it unless Part D covers Wegovy. |
| Low-Income Subsidy (LIS) | Medicare beneficiaries with LIS (Extra Help) pay 4.50–12/month, saving $1,200+ annually. |
Breaking Down the Expenses
For uninsured patients, Wegovy’s 1,349/month cost is prohibitive—only 12% of cash-paying users stay on it beyond six months due to cost. Those with commercial insurance fare better, with 68% paying under 100/month after meeting their deductible. Medicare beneficiaries face higher hurdles—only 1 in 5 Part D plans include Wegovy, and step therapy requirements delay access for 3–6 months in 42% of cases.
A six-month supply typically costs 8,094 out-of-pocket, but with insurance, that drops to 600–2,700. The best way to lower costs is checking your plan’s formulary, appealing denials with medical evidence, and using mail-order pharmacies, which sometimes offer 90-day supplies for 300–$900.
Is Wegovy Worth the Cost?
Clinical studies show Wegovy users lose 15–18% of body weight in 68 weeks, compared to 2–3% with diet/exercise alone. For those with obesity-related conditions (e.g., diabetes, heart disease), the $16,188 annual cost may still be cheaper than long-term treatments for complications. However, 32% of users stop due to side effects (nausea, diarrhea), meaning the investment doesn’t always pay off.
Part D and Wegovy
Medicare Part D covers Wegovy in only 18% of plans in 2024, leaving most beneficiaries to pay the full 1,349 monthly cost out-of-pocket. Even when covered, 87% of Part D plans require prior authorization (PA), and 42% enforce step therapy, forcing patients to try cheaper alternatives like Saxenda first. The average copay ranges from 10 to 450 per month, but with the 545 annual deductible, first-year costs can hit $5,400+ before catastrophic coverage kicks in.
”Part D plans that do cover Wegovy usually place it in Tier 3 or 4, meaning higher copays—often 33–50% of the drug’s cost. For a 65-year-old with a $30,000 annual income, that’s 7–12% of their pre-tax earnings just for one medication.”
Why Part D Coverage Is So Limited
Historically, Medicare excluded weight-loss drugs due to budget constraints. Adding Wegovy to all Part D formularies could raise premiums by 13–25 per month, a dealbreaker for the 73% of enrollees who prioritize low premiums over broad coverage. However, the FDA’s March 2024 approval of Wegovy for cardiovascular risk reduction has shifted some plans to cover it—but only for patients with BMI ≥27 plus heart disease or diabetes.
Part D’s ”protected class” rule (which guarantees coverage for drugs like antidepressants or HIV meds) doesn’t apply to weight-loss drugs, so insurers can exclude Wegovy entirely. Even when covered, PA approval rates are just 58%, with denials often citing ”lack of proof that diet/exercise failed” or ”insufficient BMI documentation.” Appeals take 14–30 days, and success rates hover at 39% without a doctor’s aggressive follow-up.
Cost Realities for Part D Enrollees
- No coverage? You’re stuck with the 1,349/month list price—16,188/year, more than double the $7,540 average annual Social Security benefit.
- With coverage but deductible not met? First-month cost is 1,349, then drops to 450/month until hitting the $5,400 out-of-pocket max.
- Low-Income Subsidy (LIS) eligible? Copays plummet to 4.50–12/month, but only 22% of Wegovy users qualify.
”A 2023 JAMA study found Part D beneficiaries with obesity pay 47% more out-of-pocket for weight-loss drugs than those with commercial insurance. For Wegovy, that gap means an extra $2,100 per year.”
Workarounds If Your Plan Excludes Wegovy
- Switch plans during Annual Enrollment (Oct 15–Dec 7)—but confirm the new formulary explicitly lists Wegovy, not just “obesity medications.”
- Use manufacturer coupons strategically: Novo Nordisk’s 500/year savings card works only if Part D covers Wegovy, but pairing it with a 0 copay in the coverage gap can save $1,000+ annually.
- Appeal with clinical evidence: Highlighting heart disease risk (if BMI ≥27) boosts approval odds by 28%.
Prior Authorization Rules
Getting Wegovy covered by insurance isn’t as simple as filling a prescription—87% of Medicare Part D and commercial plans require prior authorization (PA), a process that delays access by 7–21 days on average. In 2024, only 58% of PA requests are approved on the first try, with denials often citing missing BMI documentation (32% of cases) or lack of proof that cheaper alternatives failed (41% of cases). For patients, this means navigating a maze of paperwork, appeals, and waiting periods just to access a drug that costs $1,349/month without coverage.
Key Prior Authorization Requirements for Wegovy
| Requirement | Details | Denial Rate |
|---|---|---|
| BMI Threshold | Must be ≥30 (or ≥27 with weight-related conditions like diabetes or hypertension). | 28% (often due to outdated weight records). |
| Failed Diet/Exercise | Proof of ≥3 months of supervised weight-loss attempts with <5% body weight reduction. | 41% (insufficient documentation). |
| Step Therapy | 42% of plans require trying Saxenda or Qsymia first unless contraindicated. | 35% (patient didn’t meet step therapy rules). |
| Medical Necessity | Must show obesity-linked conditions (e.g., sleep apnea, heart disease). | 23% (doctor didn’t specify comorbidities). |
| Age Restrictions | Some plans reject patients >65 years old due to “limited long-term safety data.” | 12% (varies by insurer). |
Why Insurers Make PA So Difficult
Prior authorization isn’t just about medical oversight—it’s a cost-control tactic. Wegovy’s $16,188 annual price tag makes insurers wary: 1 in 3 approved patients discontinue the drug within 6 months due to side effects (e.g., nausea, vomiting), but insurers still foot the bill for those months. To curb spending, 73% of plans now require reauthorization every 6–12 months, forcing patients to reprove their BMI and treatment history.
The approval process itself is a bottleneck. Doctors spend 14 hours per week on average completing PAs, and 29% of Wegovy prescriptions are abandoned during the PA wait. Even when submitted correctly, insurers take 3–7 business days to respond, and appeals add another 14–30 days. For patients with severe obesity (BMI ≥35), this delay can mean 4–8 lbs of weight gain during the waiting period.
How to Improve Approval Odds
- Submit a detailed clinical history: Include dated weight records, failed diet/exercise logs, and comorbidity diagnoses (e.g., prediabetes, hypertension).
- Preempt step therapy: If your plan requires trying Saxenda first, document allergy or intolerance evidence upfront.
- Escalate quickly: If denied, file an urgent appeal within 72 hours—this cuts decision time to 24–48 hours for high-risk patients.
Alternative Coverage Options
If your insurance denies Wegovy coverage, you’re not completely out of options—but you’ll need to get creative. Only 18% of Medicare Part D plans cover Wegovy, and commercial insurers approve it just 58% of the time after prior authorization. For the 42% of patients who get denied, alternatives range from $200/month compounded semaglutide to switching insurers during open enrollment. Here’s what actually works in 2024.
One of the most effective workarounds is switching to a Medicare Advantage plan that includes Wegovy in its formulary. During the Annual Enrollment Period (October 15–December 7), you can compare plans on Medicare.gov and find one that lists Wegovy as a Tier 3 or 4 drug, which typically means 100–450/month copays after meeting the deductible. In 2024, 23% of Medicare Advantage plans cover Wegovy, up from just 12% in 2023 due to its FDA approval for cardiovascular risk reduction. If you have commercial insurance through an employer, asking HR about a formulary exception can sometimes work—about 14% of self-insured employers will add Wegovy if enough employees request it.
For those who can’t switch plans, compounded semaglutide is the most affordable alternative, costing 200–500/month at licensed pharmacies. While the FDA hasn’t approved compounded versions for weight loss, 1 in 4 Wegovy users turn to them after insurance denials. The catch? You’ll need a doctor willing to prescribe it, and quality varies widely—only 38% of compounding pharmacies meet USP standards for sterility and potency. Another option is Saxenda (liraglutide), which is covered by 62% of Part D plans and costs 300–900/month with coupons. However, it’s less effective, with average weight loss of 5–8% body weight vs. Wegovy’s 15–18%.
Manufacturer discounts can help, but with major limitations. Novo Nordisk offers a 500/year savings card, but it’s useless if your insurance outright denies coverage. Some patients use Canadian pharmacies, where Wegovy costs 700–900/month, but shipping delays of 2–4 weeks are common. If you qualify for patient assistance programs, income limits are strict—54,360/year for a single person—and approval takes 6–8 weeks.
Saving on Wegovy
Wegovy’s 1,349/month list price puts it out of reach for most patients without insurance, but strategic planning can cut costs by 50–90%. In 2024, 68% of commercially insured patients pay 25–150/month, while Medicare beneficiaries face 10–$450/month copays—if their plan covers it at all. For the 32% of users paying cash, savings options range from manufacturer coupons to international pharmacies, but each method has strict rules and limitations. Here’s how to navigate the system without overpaying.
Wegovy Cost-Saving Strategies Compared
| Method | Potential Savings | Limitations | Best For |
|---|---|---|---|
| Manufacturer Coupons | $500/year (Novo Nordisk savings card) | Doesn’t work with Medicare unless Part D covers Wegovy. | Commercial insurance users with partial coverage. |
| Low-Income Subsidy (LIS) | Reduces Medicare copays to 4.50–12/month | Only 22% of eligible patients apply. Income limit: $21,870/year (individual). | Medicare beneficiaries below 150% federal poverty level. |
| 90-Day Mail Order | Saves 100–300/refill vs. retail pharmacies | Requires insurer approval. 38% of plans restrict quantity. | Patients with stable doses (1.7mg or 2.4mg). |
| Compounded Semaglutide | 200–500/month (vs. $1,349 for brand-name) | FDA hasn’t approved for weight loss. Quality risks at 62% of pharmacies. | Cash payers denied by insurance. |
| Canadian Pharmacies | 700–900/month (requires prescription) | Shipping delays (2–4 weeks). Customs may seize orders. | Patients willing to accept supply risks. |
| Appealing Insurance Denials | Can drop copay from 1,349 to 25–$150 | 34% success rate. Takes 14–30 days. | Patients with BMI ≥30 + comorbidities. |
Timing matters when using coupons. Novo Nordisk’s 500 savings card resets every January 1, so filling a 90-day supply in December maximizes annual savings. For Medicare patients, the “coverage gap” phase (after 5,030 in total drug spending) increases Wegovy’s copay to 25% of list price (337/month), but the 500 coupon can offset this if Part D covers the drug.
Pharmacy choice impacts price. GoodRx data shows Costco charges 1,250/month, while Walmart and Sam’s Club sometimes price Wegovy at 1,100–1,200. Smaller independent pharmacies may offer 50–$75 discounts to cash payers—always ask. For those considering compounded versions, verify the pharmacy is 503B-certified (only 15% are) to avoid contaminated or underdosed products.
