Wegovy Medicare Coverage: What's Covered in 2025

Current Medicare Coverage (2025)

Covered:

• Wegovy for patients with established cardiovascular disease AND BMI ≥ 27
• Must have a history of heart attack, stroke, or peripheral arterial disease
• Coverage falls under Part D (prescription drug plan)

NOT Covered:

• Wegovy for weight loss without established CVD
• Wegovy for obesity prevention
• Semaglutide (generic) for weight loss

How to Get Medicare Coverage

1. Confirm established CVD diagnosis with your cardiologist
2. Obtain supporting documentation (cardiac catheterization reports, imaging, discharge summaries)
3. Prescriber submits prior authorization to Part D plan
4. Include SELECT trial reference to justify cardiovascular indication

If Your Medicare Plan Denies Coverage

1. File a coverage determination request
2. If denied, request a redetermination (60 days)
3. Then appeal to an Independent Review Entity (IRE)
4. Further appeals: Administrative Law Judge → Medicare Appeals Council → Federal Court

Future Coverage Expansion

CMS and Congress are considering expanding weight loss drug coverage under Medicare. Legislative efforts in 2024-2025 include the Treat and Reduce Obesity Act.