Obesity is a serious health issue affecting many older adults, impacting not only physical appearance but also overall health and increasing healthcare costs. While Medicare covers some obesity treatments, such as Intensive Behavioral Therapy and bariatric surgery in specific cases, coverage for anti-obesity medications (AOMs) remains a complex and evolving topic. This article delves into the current state of Medicare coverage for weight loss drugs, explores potential future changes, and provides guidance for beneficiaries seeking treatment options.
Current Medicare Coverage Landscape
As of 2025, Medicare Part D generally excludes drugs used solely for weight loss. This exclusion, modeled after a similar exclusion in Medicaid, was initially established to protect patient safety due to concerns about the safety and effectiveness of available weight loss drugs at the time. This means that anti-obesity drugs like Zepbound (tirzepatide) are not included unless there is a medically necessary, covered indication beyond weight loss.
Specific Scenarios:
Ozempic, Mounjaro, and Trulicity: Wellcare Medicare Advantage plans may cover these medicines for Type 2 diabetes if the drug is on your plan’s Drug List and you meet the plan criteria. They are not covered for weight loss. Medicare Part D plans may cover Ozempic when it’s prescribed for Type 2 diabetes and listed on your plan’s Drug List (formulary). Always check your plan for prior authorization, step therapy, or quality limits.
Wegovy: Wegovy may be covered only when prescribed to reduce cardiovascular risk in adults with established cardiovascular disease who are overweight or obese, and only if your plan lists it on the Drug List.
Zepbound: Zepbound may be covered when prescribed to treat obstructive sleep apnea in adults with obesity, if your plan lists it and criteria are met. Notably, Medicare will not cover Zepbound for diabetes; only Mounjaro (tirzepatide) is approved for diabetes, and Zepbound is not included on formularies for this use.
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It's important to note that coverage decisions are indication-specific. A drug may be covered for one use but not for weight loss.
The Changing Landscape of Anti-Obesity Medications
The science surrounding glucagon-like-peptide-1 (GLP-1) receptor agonists has significantly changed the conversation on anti-obesity drugs. These drugs, initially approved for treating type 2 diabetes in 2017, have shown promise in chronic weight management and, in some cases, cardiovascular disease treatment for obese or overweight patients.
GLP-1 Drugs: A Closer Look
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.
The increasing prevalence of GLP-1 drug usage, with approximately 12% of American adults currently taking them, has led to a surge in Medicare spending. Total Medicare spending on these drugs soared from $57 million in 2018 to $5.7 billion in 2022. This growth is especially remarkable given that currently Part D only covers GLP-1 drugs as treatments for diabetes or cardiovascular disease, not for weight loss alone.
Potential Future Changes in Medicare Coverage
Recognizing the evolving science and the potential benefits of AOMs, there are ongoing discussions and proposals to expand Medicare coverage for these medications.
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Biden Administration's Proposed Rule:
The Biden Administration included a provision in the proposed rule for the 2026 benefit year that proposed to “reinterpret the statutory exclusion of agents when used for weight loss such that it would not apply to drugs when used to treat beneficiaries with obesity.” The proposed reinterpretation would also apply to Medicaid as well as Medicare. However, the Trump Administration announced on April 4, 2025, that it would not broaden coverage of anti-obesity drugs in Medicare. They did not rule out reconsidering this possibility in the future, however, and others have offered policy proposals for expanding coverage of these drugs. These proposals are included in the compendium of policy options maintained by Georgetown University’s Medicare Policy Initiative (MPI).
Congressional Efforts:
Companion bills in the 118th Congress, introduced by Rep. Brad Wenstrup (R-OH) and Sen. Thomas Carper (D-DE), would have eliminated the statutory restriction on coverage of weight-loss drugs altogether. The Wenstrup bill was marked up by the House Committee on Ways and Means in June 2024, where it was amended to cover weight-loss drugs only for beneficiaries who had coverage for the drugs from a non-Medicare plan in the year before enrolling in Medicare. The latter represented a substantially lower-cost option that might offer a step in the direction of covering GLP-1 drugs at a much lower cost for the taxpayer.
CMS Pilot Program:
The Centers for Medicare & Medicare Services (CMS) is exploring a pilot that could allow some Medicaid programs and Part D plans to cover GLP-1 drugs for “weight management,” with potential Medicare availability in 2027. Details are not finalized and would go through public processes.
ACG expects continued interest in GLP-1 medications from both the administration and Congress.
Cost Considerations:
The potential expansion of AOM coverage raises significant cost considerations. The Congressional Budget Office (CBO) has analyzed an illustrative policy to add weight-loss medications to the list of Part D-covered drugs. It estimated that net federal spending would increase by $35.5 billion from 2026 to 2034. Spending on anti-obesity medicines would total $38.8 billion but would be offset by $3.4 billion in other lower medical spending. CBO assumed that prices for GLP-1 anti-obesity medications would be subject to government negotiation. In fact, Ozempic, Rybelsus, and Wegovy were placed on the list for the second round of price negotiations with the new prices effective in 2027.
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The inclusion of GLP-1 drugs would also place significant cost burdens on Part D plans, potentially leading to higher plan premiums for enrollees.
Navigating Medicare and Weight Loss Treatments
Even with the current limitations on AOM coverage, Medicare offers several avenues for beneficiaries seeking weight management support:
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. With the Intensive Behavioral Therapy program, Medicare only covers appointments that take place in a primary care setting.
Bariatric Surgery: Covered for certain conditions when medical criteria are met. In cases of severe obesity (BMI of 35 or higher), Medicare covers bariatric surgery if it’s determined by your doctor to be medically necessary. In order to secure coverage, you'll typically need to have a qualifying BMI and at least one underlying obesity-related health condition, such as diabetes or heart disease. Some bariatric procedures are specifically excluded by Medicare, such as open sleeve gastrectomy and gastric balloon.
Medicare Advantage (Part C) Plans: Some Medicare Advantage (Part C) plans provide enhanced coverage that can support your weight loss efforts.
Tips for Beneficiaries:
Consult Your Doctor: Discuss your weight management goals and explore all available treatment options. Your doctor can help determine if you meet the criteria for covered services like obesity counseling or bariatric surgery.
Check Your Plan's Drug List (Formulary): If you have a Medicare Part D plan, review the formulary to see if any GLP-1 drugs are covered for specific conditions like diabetes or cardiovascular disease.
Inquire About Prior Authorization and Step Therapy: Understand the requirements for coverage, such as prior authorization or step therapy, which may require you to try other medications first.
Consider Medicare Advantage Plans: Explore Medicare Advantage plans that may offer additional benefits for weight management.
Ask About Alternatives: If your drug is not on the Drug List, ask your prescriber about alternatives on your plan’s Drug List or whether a formulary exception may be appropriate.
Explore Cost Assistance Programs: Many members qualify for Extra Help or state assistance programs that lower drug costs. Your pharmacist or plan can help you check your eligibility.
Understanding Medicare Part D and Coverage Details
Deductible: Plans can have a deductible up to $590. You pay 100% for covered drugs until you meet it.
After the Deduction: 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 plans 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.
The Role of Advocacy and Awareness
Certain advocacy groups, such as the Obesity Action Coalition (OAC), are working on legislation to broaden access to treatment options for Medicare beneficiaries affected by obesity. For example, the Treat and Reduce Obesity Act (TROA) is a bipartisan bill designed to enable CMS to clarify that FDA-approved anti-obesity medications may be covered under Part D.
Launched on Jan. 31, 2024, the Obesity Bill of Rights is endorsed by nearly 50 national obesity and chronic disease organizations. Learn about the Obesity Bill of Rights, a set of eight patient-centered principles established to ensure people with obesity are screened, diagnosed, counseled, and treated according to medical guidelines.