Wegovy Medicare coverage: what’s covered now and what’s next

Let's get right to it because I know this question might be keeping you up at night: Is Wegovy covered by Medicare? Short answer: Yessome Medicare Part D plans now cover Wegovy for adults who have established cardiovascular disease (like a prior heart attack, stroke, or peripheral artery disease) and either obesity or overweight. The key is the FDA-approved use for reducing the risk of major cardiovascular eventsnot weight loss alone. That distinction really matters.

Now, about the money side. Wegovy isn't cheap. Costs vary a lot by plan, and you'll almost always see prior authorization, possibly step therapy, and specialty-tier coinsurance. The good news? 2025 brings an annual $2,000 Part D cap that can make the numbers more manageable. And if you're hoping to use Wegovy strictly for weight loss, there's a promising policy proposal in the worksbut it isn't guaranteed yet. I'll walk you through what's real today and what's on the horizon so you can plan with confidence.

How coverage works

Why Medicare can cover Wegovy now

Here's the turning point: Wegovy (semaglutide) received an FDA-approved indication to reduce the risk of major cardiovascular events in adults who have established cardiovascular disease and are either obese or overweight. That shift changed the game. Once a drug has a medically accepted, non-cosmetic indication, Part D plans can consider covering it for that specific use. Because Wegovy is self-injected at home, it falls under Part D, not Part B, and that's where you'll find it on formularies.

CMS also clarified that Part D plans may include Wegovy on their formularies for this cardiovascular risk reduction use. That's why you're seeing some plans quietly add it, even mid-year.

Who is eligible under current rules

To qualify under most plans today, you'll typically need documentation showing two things: 1) established cardiovascular disease (think a past heart attack, stroke/TIA, or peripheral artery disease), and 2) BMI that meets the label criteria for obesity or overweight. Plans generally look for this in your records and may ask for clinical notes or diagnostic codes.

Expect some utilization managementthings like prior authorization, step therapy (proving other options aren't appropriate or didn't work), and quantity limits. None of this means "no," but it does mean a bit of paperwork. Don't worry; I'll share a simple prep checklist below so you and your clinician can sail through it with minimal drama.

What's likely changing next

There's a proposal on the table that could reshape Medicare obesity treatment more broadly. In late 2024, an HHS/ASPE issue brief discussed pathways for allowing Part D coverage of anti-obesity medications when used for chronic weight management. If CMS ultimately reinterprets the long-standing exclusion for "agents when used for weight loss," people who have obesity without cardiovascular disease might see coverage options in upcoming plan years. It's not final policy yet, but it's a real signal.

Timing matters. You'll probably see limited but growing coverage in 2024, more expansive adoption in 2025 as plans complete their formulary cycles, and potentially lower prices later if semaglutide is selected for Medicare drug price negotiations (earliest negotiated prices could land in 2027). Translation: the trajectory is moving toward broader access and improved affordabilitybut not all at once.

Wegovy costs

Typical out-of-pocket ranges today

Let's talk numbers. Wegovy's list price sits around $1,300 per month. On a specialty tier with common coinsurance rates (often 2533%), you could be looking at roughly $325$430 per month until cost protections kick in. That's a lot, I know.

But there's help. The Inflation Reduction Act brings two big protections: reduced cost exposure in the catastrophic phase for 2024, and in 2025 a hard $2,000 annual cap on Part D out-of-pocket drug costs. That cap can dramatically change the math over a year. And if you qualify for the Low-Income Subsidy (Extra Help), your monthly cost could drop to a small copaysometimes between $0 and $15 for covered drugs. It's absolutely worth checking if you're eligible.

What affects your price

Your cost isn't just about the drug; it's about the plan. Tier placement (usually specialty), the plan's negotiated rebates, which pharmacy you choose, and where you are in your coverage phase all influence what you pay right now. Plus, prior authorization outcomes and step therapy decisions can impact when coverage starts and under what conditions.

Plans may ask whether you tried other therapies or whether you have documentation of qualifying cardiovascular disease. This isn't to make your life hard; it's part of how they manage spending and ensure appropriate use. Having your paperwork ready saves time and energy.

Budgeting and savings tips

Before your clinician hits "send" on that prescription, check your plan's formulary and coverage rules. If Wegovy isn't coveredor the hoops are too manyask about related GLP-1 medications that might be covered for your specific conditions. For example, Ozempic (also semaglutide) is typically covered for diabetes and may also help with cardiovascular risk in people with diabetes. It's not the same indication as Wegovy's new label, but it may be a practical option depending on your diagnosis and your plan's rules.

If you get denied, you have appeal rights. Don't let that first "no" be the end of the road. A stronger letter from your clinician, citing the cardiovascular indication, highlighting your risk profile, and documenting prior therapies, can turn things around. Keep copies of everythingletters, explanations of benefits, prior test results, BMI documentation. Think of it as building your coverage case file.

Wegovy eligibility

Clinical criteria today

Eligible diagnoses for established cardiovascular disease usually include a prior myocardial infarction (heart attack), stroke or TIA, or peripheral artery disease. You'll also need to meet the BMI threshold spelled out in Wegovy's label for overweight or obesity. Your clinician can confirm those details and include them in the prior authorization.

Documentation is the magic ingredient here. Notes from your cardiologist, hospital discharge summaries from a past event, and your current vitals and BMI all help. If your records live in different systems, request them now so your prior authorization doesn't get stuck waiting on faxed pages from three clinics.

If you have diabetes

If you live with type 2 diabetes, you might already know Ozempic (injectable semaglutide) or Rybelsus (oral semaglutide). These can be covered when used for diabetes management and may also reduce cardiovascular risk in people with diabetes. Wegovy is specifically approved for cardiovascular risk reduction in people with CVD plus obesity or overweightregardless of diabetes status. Plans will avoid duplicate therapy, so don't expect to use multiple GLP-1s at the same time. Your clinician can help decide which agent fits your diagnosis and coverage best.

If you want Wegovy for weight loss alone

Here's the sticking point: Medicare has historically excluded "agents when used for weight loss." That's why weight loss medication Medicare coverage has been so limited. The difference now is Wegovy's cardiovascular indication, which opens the door for a subset of people.

But change may be coming. Policy analysts and CMS are exploring ways to allow Medicare obesity treatment under Part D for chronic weight management, not just cardiovascular risk reduction. If that reinterpretation becomes policy, coverage could expand to people with obesity but without established CVD. Keep an eye on your plan's Annual Notice of Change and formulary updates for 2025 and beyond. And if you're considering Wegovy for weight loss alone, talk with your clinician about timing, alternatives, and what to watch for in your plan's materials.

Other care options

Covered care today

Medicare already covers several layers of support that can help with weight, heart health, and overall well-being. Intensive behavioral therapy for obesity, medical nutrition therapy for qualifying conditions, and programs like cardiac rehab (if you meet criteria) are surprisingly powerful when used consistently. They're also the kind of care that plays well with medicationless "either/or," more "both/and."

Many GLP-1s are covered for diabetes, and some have cardiovascular indications specifically in the diabetes population. If you're not eligible for Wegovy today, a diabetes-focused GLP-1 might still be appropriate and covered if you have type 2 diabetes. It's worth a conversation with your clinician and your plan.

Other anti-obesity medications

Most stand-alone anti-obesity medications are still excluded under Medicare rules when used solely for weight loss. A handful of enhanced Part D plans experiment with supplemental benefits, but these are exceptions rather than the norm. If you're dual-eligible (Medicare and Medicaid), check your state's Medicaid rulessome states provide coverage pathways that Medicare alone does not. Dual-eligibility can change the affordability picture dramatically.

Benefits and risks

Why Wegovy can help

If you have established cardiovascular disease and meet the BMI criteria, Wegovy's FDA-approved use is to reduce the risk of major cardiovascular events. That's not a small benefit; we're talking about heart attacks and strokesthe big stuff. Many people also experience significant weight loss and improvements in metabolic health, which can help with energy, mobility, and day-to-day life. I've heard patients describe it like "finally getting the volume turned down on constant hunger," which can be incredibly validating after years of struggling.

Risks and side effects

As with any medication, there are trade-offs. Common side effects include nausea, vomiting, diarrhea, constipation, and abdominal discomfortespecially during dose increases. Most people find these manageable with slow titration, hydration, and a little patience, but some stop treatment because the symptoms are too disruptive. Rare but serious risks exist, so your clinician will screen for contraindications like a history of certain thyroid tumors, and they'll review potential drug interactions. Good follow-up and honest check-ins are key to staying safe and comfortable.

Access and equity

Let's name the hurdles: prior authorization paperwork, potential supply constraints, and the cost before you hit caps or qualify for Extra Help. These barriers don't fall equally on everyone. If you qualify for the Low-Income Subsidy, your access can improve dramatically. If you don't, the 2025 Part D $2,000 cap can still be a game-changer. And yes, appeals workespecially with clear medical documentation and a clinician who's willing to advocate for you.

On days when the process feels heavy, remember your "why." Reducing the risk of another heart event is worth the effort. You're not asking for a favoryou're pursuing evidence-based care that aligns with national guidelines and evolving policy.

Check coverage steps

Verify your plan

First, log into your Part D or Medicare Advantage plan's member portal and open the formulary tool. Search for semaglutide (Wegovy). If there's a note about coverage only for cardiovascular risk reduction or certain BMI thresholds, that's normal. Write down the tier, coinsurance percentage, and any utilization flags like prior authorization or step therapy. If your plan lists Wegovy as "non-formulary," call the number on your card and ask whether there's a medical exception process for the FDA-approved cardiovascular indication.

Prepare your documentation

Next, team up with your clinician. You'll want to include: 1) your CVD diagnosis (MI, stroke/TIA, PAD), 2) BMI that meets the label criteria, 3) current meds and any prior therapies tried or not tolerated, and 4) your cardiovascular risk profile (like lipid levels, blood pressure, diabetes status). If you've had a hospitalization, keep those discharge summaries handy. Clear, concise notes can shave days off the prior authorization timeline.

Submit and appeal if needed

Once your clinician submits the prior authorization, track the status online or by calling your plan. If you're denied, don't panic. Ask for the reason in writing, then file an appeal with a strong letter that ties directly to the FDA indication and your medical necessity. Include any new evidence your plan requested. In some cases, you can ask for a temporary supply or explore covered alternatives while the appeal is pending. Persistence pays off here.

Evidence and trust

We're leaning on the official FDA labeling and safety information for Wegovy's cardiovascular risk reduction indication, the CMS Part D Manual and related memos that allow coverage of self-injected drugs with medically accepted indications, and respected independent analyses on program costs and timing. According to a KFF analysis, coverage pathways, costs, and timelines will likely evolve over the next few years as policies and negotiations take shape. And an HHS/ASPE issue brief outlines how a reinterpretation could open Medicare obesity treatment more broadly under Part D, with important budget and equity considerations.

If you want expert perspective layered in, cardiologists and endocrinologists can help pinpoint who benefits most from Wegovy and how to monitor for side effects and cardiovascular outcomes. Pharmacists are gold when it comes to navigating coverage hurdles, appeals, and adherence strategiesespecially during dose titration.

And yes, real-world stories matter. I think of a patient with a prior MI who got an initial denial; their cardiologist wrote a clear, evidence-based letter focused on the cardiovascular indication and risk profile, and the approval came through in days. Another person on Extra Help paid a fraction of the cost compared to their neighbor without LIS. Same drug, totally different financial experience. These differences aren't fair, but knowing your toolsappeals, LIS, plan comparisonslets you tilt the field in your favor.

Final thoughts

Wegovy Medicare coverage is opening upmainly for people with established cardiovascular disease plus obesity or overweightthrough Part D. That's genuinely encouraging if your goal is reducing your risk of heart attack or stroke. Still, expect guardrails: prior authorization, possible step therapy, and meaningful coinsurance until annual caps apply. If you're seeking Wegovy for weight loss alone, keep an eye on the evolving CMS policy discussion that could expand Medicare obesity treatment in future plan years.

Here's your next best step: check your plan's formulary today, talk with your clinician about whether you meet the cardiovascular indication, and gather the documentation you'll need for prior authorization. If you might qualify for Extra Help, applyit can be a financial lifesaver. And if you want help comparing plans or prepping an appeal, tell me your ZIP code and current plan. We'll walk through it together, one step at a time. What questions are on your mind right now?

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.