How to Get Ozempic or Mounjaro Through Medicare

If you’ve been hearing about Ozempic or Mounjaro as treatment options for type 2 diabetes or weight loss, you might be wondering: Does Medicare cover these medications? And if so, how can you get them covered under your plan?
In this post, we’ll explain what you need to know about obtaining these medications through Medicare, including coverage details, how to get them, and potential out-of-pocket costs.
Before diving into how to get these medications through Medicare, let’s take a quick look at what Ozempic and Mounjaro are.
  • Ozempic (semaglutide) is a GLP-1 receptor agonist used to manage type 2 diabetes and is also approved for chronic weight management in certain patients.
  • Mounjaro (tirzepatide) is a newer GLP-1 and GIP receptor agonist used to treat type 2 diabetes and has shown promising results in helping with weight loss as well.
These medications are injectable, typically administered once a week, and have become a popular option for individuals with type 2 diabetes or those seeking weight management solutions. However, when it comes to obtaining these medications through Medicare, there are a few key things you need to know.

What Are Ozempic and Mounjaro?

Medicare Coverage for Ozempic and Mounjaro

Medicare Part D: Prescription Drug Coverage

Medicare Part D is the part of Medicare that helps cover prescription drugs. Since Ozempic and Mounjaro are both prescription medications, they may be covered under Part D if they are prescribed by your doctor for an FDA-approved indication, such as diabetes management.

Ozempic:

Ozempic is covered by most Part D prescription drug plans. Formulary status: Depending on the plan, Ozempic may be listed on the formulary (the list of covered drugs), often under higher tiers. Coverage and co-pays can vary by plan, so it’s important to review your plan’s formulary to confirm coverage.

Mounjaro:

  • Mounjaro is newer than Ozempic and may not be included on all Part D formularies.However, it is expected to be covered by many plans in 2026.
  • Formulary placement: Mounjaro is likely to be placed in higher drug tiers because it’s a newer and more expensive medication.
  • If it’s not on your current plan’s formulary, you may need to discuss prior authorization or exceptions with your insurance provider.

How to Get Ozempic or Mounjaro Through Medicare Part D

  1. Check Your Plan’s Formulary:
    • Every Part D plan has a formulary that lists the drugs covered by the plan. Start by reviewing your plan’s formulary to see if Ozempic or Mounjaro is covered and in which tier.
    • If you’re not sure where to find this information, your Medicare advisor can help guide you through the process.
  2. Talk to Your Doctor:
    • Prescription Requirement: Your doctor must prescribe Ozempic or Mounjaro. Ensure your doctor knows you want these specific medications for diabetes or weight management.
    • Medical Necessity: If the medication is not on your plan’s formulary, your doctor may need to submit a prior authorization request or support an exception request to get the medication approved.
  3. Review Your Plan’s Coverage:
    • Once you’ve confirmed that the medication is covered, check the costs. Most Part D plans require co-pays or coinsurance for prescription medications, and Ozempic and Mounjaro can be expensive.
    • Be aware of any deductibles or coverage gaps that could affect your out-of-pocket costs. Your Medicare advisor can help you compare plans if you’re concerned about affordability.
  4. Explore Extra Help or Financial Assistance:
    • If you qualify for Medicare’s Extra Help program, you could receive financial assistance with prescription drug costs, including Ozempic and Mounjaro.
    • Additionally, manufacturer discount programs may be available for Ozempic and Mounjaro to help reduce costs.

What to Expect for Costs

The cost of Ozempic or Mounjaro through Medicare depends on several factors:
  • Your Part D plan and its formulary
  • Whether the medication is in a preferred tier
  • Any deductibles, co-pays, or coinsurance
  • Extra Help or other assistance programs you may qualify for
In general, newer medications like Mounjaro may have higher out-of-pocket costs due to their higher price tag, and you might see higher co-pays if the medication is placed in a higher tier on your plan’s formulary.

Choosing the Right Medicare Coverage

Selecting the best Medicare coverage depends on factors like your healthcare needs, budget, and preferred providers. You can choose between:
  • Original Medicare (Parts A & B): Allows you to see any doctor or
    hospital that accepts Medicare but does not include prescription drug
    coverage (Part D) or additional benefits.
  • Medicare Advantage (Part C): Offers bundled coverage with
    potential extra benefits but may require using a network of providers.
  • Medigap (Medicare Supplement Insurance): Helps cover
    out-of-pocket costs not covered by Original Medicare, such as
    copayments and deductibles.

Key Medicare Enrollment Periods

It is crucial to enroll in Medicare at the right time to avoid penalties and ensure continuous coverage:
  • Initial Enrollment Period (IEP): A seven-month window starting
    three months before your 65th birthday month.
  • General Enrollment Period (GEP): From January 1 to March 31
    each year for those who missed their IEP.
  • Annual Election Period (AEP): From October 15 to December 7,
    allowing you to switch or enroll in Medicare Advantage and Part D
    plans.
  • Open Enrollment Period(OEP): From January 1 to March 31 for
    those who missed AEP and want to make certain changes.
  • Special Enrollment Period(SEP): Can be used anytime during the
    calendar year for those that meet certain criteria such as moving to a
    new service area.

Finding Help with Medicare

Understanding Medicare can be complex, but you don’t have to do it alone. Licensed Insurance Brokers, Medicare.gov, and state health assistance programs can provide guidance tailored to your specific needs.
By taking the time to explore your Medicare options, you can make informed decisions that ensure you receive the healthcare coverage that best suits your lifestyle and budget.
Do I have to sign up for Medicare?
It depends upon your current coverage. If you are employed and your employer has over 20 employees then you can delay signing up for Medicare and avoid penalties.
No, You will have to enroll in a stand alone Part D plan or a Medicare Advantage Plan(Part C) to get coverage.
There are no networks with Medicare and most doctors and hospitals accept it. However, Medicare does not cover 100% of services so a Medicare Supplement or Medicare Advantage plans is advisable.

Mike Miligi- Owner

For over 10 years, Mike has been assisting Seniors and other Medicare-eligible individuals in understanding the ins and outs of Medicare and Medicare Health Insurance options, including Medicare Advantage Plans(Part C), Medicare Supplement Plans(Medigap), Prescription Drug Plans(PartD), and Dental and Vision programs.
Mike is Licensed in seven States and Certified with 11 Insurance Carriers. He has helped thousands of individuals decide on the best course of action for their particular Health Insurance needs. Because Mike is an Independent Medicare Health Insurance Broker, he works for the client, not the Insurance Carriers, and is able to provide his clients with accurate and unbiased Health Insurance options.
Mike recertifies with CMS(The Centers for Medicare and Medicaid Services) annually, regularly completes Continuing Education Courses required by individual State Insurance Departments, and keeps abreast of industry trends and standards to offer his clients the most up-to-date information.
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