With new medications like Ozempic and Wegovy, choosing weight loss options through the Department of Veterans Affairs (VA) can feel a bit more overwhelming. While there is a bit of a fuse on how effective these medications are, how does the VA regard these medicines? Here is a look at everything you need to know about coverage, eligibility, and important factors for veterans who are interested in these treatments.
Does the VA cover Ozempic or Wegovy for weight loss?
Indeed, the VA may provide coverage for those medications for weight loss like Ozempic and Wegovy, but there are certain criteria which are required for you to meet. Both of these medications are not included in the VA’s National Formulary by weight-loss indication, thus they are considered as “non-formulary” agents. That means, although it is available to the patient through the VA, they will only be given with prior authorization and consideration of their medical history with eligibility under the VA’s Criteria for Use (CFU).
Here are the main points to know:
- Ozempic (semaglutide) is primarily approved for managing type 2 diabetes but has been found to aid in weight loss.
- Wegovy (a higher dose of semaglutide) is specifically approved by the FDA for chronic weight management.
- The VA does not approve these medications for cosmetic weight loss. They are prescribed only when medical conditions, such as type 2 diabetes or obesity with related health issues, make their use medically necessary.
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Eligibility requirements for Ozempic or Wegovy through the VA
To qualify for these medications under the VA benefits, you need to meet strict eligibility requirements. These criteria ensure the medication is used appropriately and alongside a comprehensive weight management program.
Here is what the VA typically looks for:
- Body mass index (BMI):
- BMI of 30 or higher (obesity)
- BMI of 27 or higher with at least one weight-related condition, such as hypertension, type 2 diabetes, or sleep apnea
- Lifestyle intervention participation:
- You must be actively involved in a structured weight management program, such as the VA’s MOVE! program, which focuses on diet, physical activity, and behavioral changes.
- Medical necessity:
- A documented need for weight management due to a chronic condition directly related to obesity.
How does the VA decide on non-formulary medications?
Because Wegovy and Ozempic are non-formulary, your VA healthcare provider must justify their use by demonstrating that they are the most appropriate treatment for your situation. This process involves several steps:
- Clinical review: Your provider will evaluate your health records, weight loss history, and response to other treatments.
- Prior authorization: Approval from the VA’s pharmacy team is required before the prescription can be filled.
- Ongoing monitoring: Continued use of these medications depends on meeting specific weight loss goals and maintaining progress over time.
If you do not achieve significant weight loss (usually at least 5% of your baseline weight) within the first few months, the medication may be discontinued.
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What does the VA’s MOVE! program involve?
The VA emphasizes a holistic approach to weight management, which is why participation in the MOVE! program or a similar intervention is required for coverage of weight-loss medications. MOVE! is a comprehensive lifestyle program that focuses on:
- Dietary changes: Personalized meal plans to help you adopt healthier eating habits.
- Exercise: Physical activity tailored to your abilities and goals.
- Behavioral support: Counseling to address emotional and psychological factors tied to weight management.
The program is designed to help veterans achieve sustainable weight loss, whether or not medications like Wegovy or Ozempic are prescribed.
How much does Wegovy or Ozempic cost through the VA?
If approved, the cost of these medications through the VA is significantly reduced compared to retail prices. However, you will still need to cover your copayment, which varies based on your priority group and income level. For veterans in priority groups 1 – 3, copayments are often lower.
Without VA coverage, these medications can cost over $1,000 per month, making VA benefits a valuable resource if you are eligible.
What you can do now
If you are a veteran considering Ozempic or Wegovy for weight loss, start by speaking with your VA healthcare provider. They can assess your eligibility, help you enroll in the MOVE! program, and guide you through the approval process for non-formulary medications. Weight loss is a journey, but with the right support, you can take steps toward improved health.
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