The landscape of Medicare coverage for weight loss medications, particularly tirzepatide (Zepbound), is complex and evolving. While current federal regulations generally exclude drugs solely for weight management from Medicare Part D, there are limited exceptions and potential future changes on the horizon. As of October 2025, understanding the nuances of these regulations is crucial for both healthcare providers and Medicare beneficiaries.
Current Medicare Coverage Policies
As of 2025, Medicare Part D plans generally do not cover Zepbound for weight loss. This exclusion is rooted in long-standing federal regulations that prevent Medicare from covering medications exclusively used for weight management. This restriction stems from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Exceptions for Obstructive Sleep Apnea (OSA)
There are limited exceptions to this rule. Some Medicare Part D or Medicare Advantage (Part C) plans may offer coverage for Zepbound if it is prescribed specifically for the treatment of obstructive sleep apnea (OSA) in adults with obesity. However, even in these cases, coverage is not guaranteed.
To obtain coverage for Zepbound for OSA, a prescriber typically needs to demonstrate medical necessity according to the specific plan's rules. This often involves providing documentation that supports the need for the medication to treat the OSA.
Medicare Part D vs. Medicare Advantage (Part C)
It's important to distinguish between Medicare Part D and Medicare Advantage (Part C) plans. Medicare Part D is a standalone prescription drug plan that works alongside Original Medicare (Parts A and B). It provides coverage for prescription medications but does not cover hospital or medical services.
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Medicare Advantage (Part C) plans, on the other hand, are an alternative way to receive Medicare benefits. These plans are offered by private insurance companies and often include Part D drug coverage along with other benefits, such as vision, hearing, and dental care. However, both Part D and Part C plans must adhere to the federal regulations that restrict coverage for weight loss drugs.
The Role of Formularies
Medicare Part D and Part C plans use formularies, or drug lists, to determine which medications they cover and at what cost. These formularies categorize drugs into different tiers, with higher tiers generally associated with higher out-of-pocket costs.
Even if a plan covers Zepbound for OSA, the specific tier placement of the drug on the formulary will affect the beneficiary's cost. Plans typically include a deductible and a monthly premium, further influencing the overall expense. According to CMS, the national base beneficiary premium for Part D in 2025 is $36.78, while the average monthly premium for Part C is about $17.
The Case of Tirzepatide: Zepbound and Mounjaro
Tirzepatide is available under two brand names: Zepbound and Mounjaro. While both medications contain the same active ingredient (tirzepatide), they are approved for different indications. Mounjaro is approved for the treatment of type 2 diabetes, while Zepbound is approved for weight loss and management.
Notably, Medicare will not cover Zepbound for diabetes; only Mounjaro is approved for diabetes, and Zepbound is not included on formularies for this use. This distinction is important because Medicare Part D plans may cover Mounjaro when prescribed for type 2 diabetes if the drug is on the plan’s Drug List (formulary).
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The High Cost of Weight Loss Medications
A significant challenge for both health insurers and individuals who could benefit from weight loss drugs is the cost. Without insurance, a month's supply of medications like Wegovy can cost up to $1,400. Zepbound can also cost more than $1,000 out of pocket, depending on the dispensing pharmacy. A person who does not qualify for coverage under their Medicare plan will have to pay the full cost.
This high cost creates a barrier to access for many beneficiaries, highlighting the need for potential solutions such as expanded coverage or financial assistance programs.
Potential Future Changes: 2026 and Beyond
Despite the current restrictions, there is hope for expanded Medicare coverage of weight loss medications in the future. The Centers for Medicare & Medicaid Services (CMS) is exploring a pilot program that could allow some Medicaid programs and Part D plans to cover GLP-1 drugs for "weight management," with potential Medicare availability as early as 2027.
CMS had proposed an expansion for 2026 but the administration decided against moving forward with it. Details are not finalized and would go through public processes.
The Treat and Reduce Obesity Act
In 2013, the Treat and Reduce Obesity Act was introduced, signaling a growing recognition of obesity as a disease that requires comprehensive treatment options.
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Potential Impact of Expanded Coverage
Expanded coverage of weight loss medications could have a transformative impact on healthcare. "These obesity medications are game changers," said Dr. Ryan. "They have great potential to transform medical care."
Strategies for Accessing Zepbound When Coverage Is Limited
If Zepbound is not covered by a Medicare plan, there are several strategies that may help with accessing this medication:
- Ask about alternatives: Talk to your doctor about alternative medications that are on your plan’s Drug List.
- Formulary exception: Inquire with your plan about whether a formulary exception may be appropriate.
- Extra Help program: Check your eligibility for the Extra Help program or state assistance programs that lower drug costs. Many members qualify for these programs. Your pharmacist or plan can help you check your eligibility.
The Role of GLP-1 Receptor Agonists
Many weight loss medications, including tirzepatide, belong to a class of drugs called glucagon-like peptide-1 (GLP-1) receptor agonists. These medications work by mimicking the effects of the GLP-1 hormone, which helps to regulate blood sugar and appetite.
How GLP-1s Work
GLP-1 medicines help your body control blood sugar and can lower appetite. They signal your pancreas to release insulin when needed, slow how fast food leaves your stomach and reduce sugar made by your liver. Doctors mainly prescribe them for Type 2 diabetes.
Coverage Considerations for GLP-1s
GLP-1 coverage can feel complex. As a general rule, Medicare does not cover GLP-1 receptor agonists for treating weight loss alone. However, if a medication has an FDA-approved indication beyond weight loss, Part D plans may cover it for that specific use. Coverage decisions are indication-specific. A drug may be covered for one use but not for weight loss.
Navigating Medicare Coverage for Medications: Key Steps
To make the most of your next appointment and help your doctor match treatment to your plan, it's essential to be prepared. Here are some key steps:
- Check your plan details: Review your plan details and Drug List results to understand which medications are covered and at what cost.
- Prior authorization: If prior authorization is needed, start with your doctor. Your plan reviews the request and sends a decision to you, your doctor, and your pharmacy.
- Step therapy: If step therapy applies, you may need to try a covered alternative first.
- Understand costs: Be aware that your costs depend on your specific plan, the pharmacy you use, and whether your medication is covered for your diagnosis.
Understanding Medicare Costs
- Deductible: Plans can have a deductible up to $590. You pay 100% for covered drugs until you meet it.
- After the Deductible: You generally pay 25% coinsurance for covered drugs until you reach the annual $2,000 out-of-pocket maximum.
- Drug Tiers Matter: High-cost medicines are often on a "specialty" tier. Plans can set specialty-tier coinsurance between 25% and 33% depending on the plan's deductible.
- Special Cases: Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are $0, and covered insulin is capped at $35 for a one-month supply.
Note: The $2,000 cap and the above rules apply only to covered Part D drugs.
Additional Medicare Benefits for Weight Management
Even if a medicine isn’t covered for weight loss, Medicare still pays for several services that help manage weight and related conditions.
Obesity Counseling Under Part B
Medicare covers intensive behavioral therapy when you have a Body Mass Index (BMI) of 30 or more and you receive counsel from a primary care practitioner in a primary care setting.
Bariatric Surgery
Bariatric surgery is covered for certain conditions when medical criteria are met.
The Stigma of Obesity and the Need for Comprehensive Coverage
Despite obesity being classified as a disease - not a failing of lifestyle choices, as stigma around the condition perpetuates - coverage of obesity-related medications is sorely lacking.
Addressing this stigma and expanding access to comprehensive obesity treatments, including medications like Zepbound, is crucial for improving the health and well-being of Medicare beneficiaries.
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