Over 34.2 million people across the United States have a diabetes diagnosis. About an estimated 7.3 million without the diagnosis have the disease and are unaware of it.
Living with type 2 diabetes requires consistent management, which is usually done with the use of certain medications. One of the newer options is Mounjaro (tirzepatide), which has gained much attention in recent years. However, it’s also one of the most expensive medications on the market.
But does Medicare cover Mounjaro for type 2 diabetes, and to what amount?
Mounjaro is a relatively new injectable medication designed to manage type 2 diabetes. It belongs to a class of drugs called GLP-1 receptor agonists.
This class of drugs functions by mimicking the hormone GLP-1. By taking the place of this hormone, patients can increase insulin secretion, slow gastric emptying, and help regulate blood sugar levels.
With type 2 diabetes, the body doesn’t produce enough insulin due to the destruction of your pancreatic beta cells. Individuals also gain insulin resistance and fail to secrete enough insulin to manage their increasing glucose levels.
Patients take Mounjaro once a week via injection, which makes it a convenient option for those who dislike pills of fast-acting insulin.
The biggest issue with Mounjaro is the cost. Currently, not many insurance policies cover much of that cost, if any. As a result, many type 2 diabetics could benefit from this medication but lack the funds to afford it every month if at all.
Both Medicare and Medicaid can potentially cover some of your Mounjaro payment, but it depends on the plan and your current status. Medicaid is a needs-based program, while any senior or disabled individual can qualify for Medicare.
There are four parts of Medicare to consider when you apply for it.
Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care. It costs nothing for anyone who qualifies for Medicare. People also refer to it as “premium-free Part A.”
The second part is your medical insurance. It covers services, things like:
Medical equipment covered by this part includes wheelchairs, walkers, and hospital beds. Preventative services include screenings and vaccines.
A Medicare Advantage plan differs from Original Medicare in that a private company provides it. Original Medicare includes Part A and Part B. Part C refers to bundled plans that include both of those parts as well as Part D.
The benefit of Part C is that you may have lower out-of-pocket costs and some extra benefits, such as vision and dental. However, you’ll need to use doctors in the plan’s network.
Part D covers the cost of prescription drugs. This is the part you’d expect to cover some, if any, of your Mounjaro purchase.
You can get drug coverage by either joining a drug plan on top of your Original Medicare or by joining a Medicare Advantage plan. As such, it’s one of the most versatile parts of Medicare.
Mounjaro prescription costs will depend on four main factors:
Past that, it’ll all depend on how much you can afford in your budget.
Neither Medicare Part A nor Part B deals with Mounjaro. The first focuses on inpatient care and does not cover injections administered at home. The same applies to Part B, which only covers injections administered by a healthcare provider.
Medicare Advantage plans often include prescription drug coverage. The extent will depend on the plan you purchase. Part D focuses entirely on prescription drugs and is where you’ll find coverage for diabetes medications.
Most Medicare Part D plans have some kind of annual deductible you have to meet before they cover your prescriptions. A deductible is the amount someone must pay before their insurance contributes.
For example, you might need to spend over $2,000 of your own money before your insurance kicks in. Plans with lower monthly premiums tend to have higher deductibles.
Once you meet your deductible, you either pay a copayment or coinsurance. Copayments are fixed amounts, while coinsurance is a percentage of the drug cost.
Since Mounjaro is a higher-tier drug, it will come with a higher out-of-pocket cost.
Medicare sets a specific limit on how much they can cover for your medications. Once your total drug costs exceed this limit, you enter the Coverage Gap.
When you’re in this gap, you will pay a higher percentage of your drug costs.
The good news is that once you leave the Coverage Gap, you enter the Catastrophic Coverage Stage. When in this stage, you only pay a small coinsurance amount or copayment for medications.
You have a few different options to find out what Medicare benefits and coverage you have.
To begin, you can obtain your plan’s formulary online. A formulary is a list of prescription drugs covered by your Medicare plan. The different tiers indicate restrictions such as prior authorization, quantity limits, or step therapy.
If you have the option of changing your plan, you can use the Medicare Plan Finder to search for and compare plans. Use the tool to add your prescription drugs and display plans that cover them.
Your last option is to contact Medicare directly. Ask them about any changes or how you can get better coverage for medications like Mounjaro.
Does Medicare cover Mounjaro for type 2 diabetes treatment? Despite how game-changing the medication is for diabetics, most plans offer very little coverage for the drug. It all depends on the Medicare Advantage plan you invest in.
Family Medicine Austin provides comprehensive care for individuals and families throughout Austin, Texas. Our services cover diabetes treatments, women’s health, hormone replacement therapy, and more. Contact us today with any questions and to set up your first visit.
