Does Medicare Cover Mounjaro?

Mounjaro has been prescribed to treat patients with Type 2 diabetes since it was approved by the FDA in 2022, but Mounjaro has entered many recent discussions in the headline-making weight-loss journeys of several celebrities. If you’re wondering if you should ask your doctor about Mounjaro, learning more about the medication may increase your understanding.

According to the FDA, “Mounjaro was effective at improving blood sugar and was more effective than the other diabetes therapies with which it was compared in clinical studies.” In November 2023, the active ingredient in Mounjaro, Zepbound, was approved by the FDA to treat obesity. Millions of Americans who struggle with obesity may consider medical intervention to help in their weight loss efforts.

How does Mounjaro work?

Your pancreas makes a hormone called insulin to propel blood sugar into cells for energy production. A disruption of this process results in unhealthy levels of glucose in your blood, known as blood sugar. Type 1 diabetes is when your pancreas fails to produce insulin. Type 2 diabetes, the more common form, is when insulin is available but not used properly, a condition known as insulin resistance. 

Some people with Type 2 diabetes can manage their blood sugar levels with lifestyle changes, improving behaviors with a focus on nutrition and physical activity. Others need to add injections of insulin or other medication like Mounjaro to their treatment plan. 

The Food and Drug Administration (FDA) states that over 30 million people in the United States have Type 2 diabetes. Although numerous medications are available to treat the disease, many patients are not achieving the appropriate blood sugar levels. 

Approximately 40 million Americans are considered obese and are at risk of developing other conditions and diseases as a result. If you’re eligible for Medicare, will it help cover the cost of Mounjaro for weight loss? 

Private insurers selling Medicare-approved drug plans determine the drugs covered and the patient’s portion of the cost. The standard formulary, the covered drug list, is tiered with levels differentiated by brand, generic and specialty drugs. 

Medicare coverage for Mounjaro will depend on the reason it’s prescribed and what Part D plan you joined. Whether you purchased a stand-alone Medicare Prescription Drug Plan or have prescription drug coverage through a Medicare Advantage plan with prescription drug coverage(MA-PD), you should have access to the formulary to check benefits. Your cost for Mounjaro depends on your plan’s deductible and coinsurance or copayment. Be sure to check requirements and limits also, such as prior authorization and maximum quantity.

If your doctor has prescribed Mounjaro to treat type 2 diabetes, you may have coverage through Part D. However, Medicare generally does not cover medications prescribed solely for weight loss.

Weight loss and nutrition

Medicare does not cover Mounjaro as a weight-loss drug, however, Medicare does offer nutrition support to eligible beneficiaries. Medicare Part B offers nutrition therapy as a preventive service, with a doctor referral, to beneficiaries with diabetes or kidney disease. If Medicare approves the service, a Medicare-participating nutrition professional, such as a registered dietitian, provides the service at no cost. The Part B deductible and coinsurance do not apply. 

Some Medicare Advantage plans include coverage for additional benefits beyond Part A and Part B. Some MA plans include fitness programs, like SilverSneakers. Ask your doctor if you have concerns about your health, weight, or any symptoms of diabetes you may experience. 

Some Medicare Advantage plans include coverage for additional benefits beyond Part A and Part B. Some MA plans include fitness programs, like SilverSneakers. Ask your doctor if you have concerns about your health, weight, or any symptoms of diabetes you may experience.