Medicare does not cover Ozempic for weight loss unless linked to specific conditions like diabetes, but rules are changing with a new pilot program starting in 2026. Beneficiaries should be aware of the eligibility requirements and potential costs associated with this medication.
Navigating Medicare coverage for Ozempic can be complex, particularly since it is not currently covered for weight loss alone. With upcoming changes in policy and potential new options for beneficiaries, understanding the specifics of coverage, costs, and eligibility is essential for seniors considering this treatment.
Key Takeaways
- Federal law prohibits Medicare from covering weight-loss drugs like Ozempic unless they are prescribed for conditions such as diabetes.
- A CMS pilot program starting in July 2026 will allow eligible beneficiaries to pay $50 monthly copays for GLP-1 medications.
- To qualify for coverage under the pilot, beneficiaries must have a BMI over 35 or a BMI of 27 with certain health conditions.
- The list price of Ozempic is approximately $997.58 per month, but costs could drop significantly under the new pilot program.
- Plans must opt-in to the pilot program, meaning not all Part D or Medicare Advantage plans will offer coverage.
- The FDA has approved an oral version of Wegovy, a GLP-1 medication, expected to be available in pharmacies by early January 2026.
Related questions people ask
- What is Ozempic?
- What is Ozempic used for?
- What does Ozempic do for weight loss?
- How does Ozempic help with weight loss?
- How do you get prescribed Ozempic?
- How do you qualify for Ozempic?
- How can I get Ozempic without insurance?
- How much does Ozempic cost without insurance?
- Is Ozempic covered by insurance?
- Does insurance cover Ozempic for weight loss?
- What insurance covers Ozempic?
- What are the eligibility requirements for Ozempic?
- What is the cost of Ozempic with insurance?
- What is the best time to take Ozempic?
- How long does it take for Ozempic to work?
- What are the side effects of Ozempic?
- Can you take Ozempic if you don’t have diabetes?
- What are the benefits of Ozempic?
- What is the difference between Ozempic and Wegovy?
- What weight loss medications are covered by Medicare?
- What alternatives are there to Ozempic?
Understanding Medicare’s Coverage for Ozempic and Similar Drugs
Federal Restrictions on Weight-Loss Drug Coverage
Medicare’s coverage of medications is tightly regulated, particularly when it comes to weight-loss drugs. Under current federal law, Medicare does not cover weight-loss medications, including Ozempic, unless they are prescribed for specific medical conditions such as diabetes or heart disease.
Upcoming Changes in Coverage Policies
Significant changes are on the horizon for Medicare coverage of weight-loss medications. Starting in July 2026, the Centers for Medicare & Medicaid Services (CMS) will launch a pilot program that allows for coverage of GLP-1 medications, including Ozempic, for eligible beneficiaries, with a copay of $50 after deductibles.
Cost Implications for Medicare Beneficiaries
Monthly Copays and Government Contributions
For those enrolled in the upcoming pilot program, the monthly copay for Ozempic will be set at $50 after meeting deductibles. The government will contribute approximately $245 per month for GLP-1 medications, which aligns with similar support provided under Medicaid.
Price Reductions and Cash Options
Currently, the list price for a monthly injection of Ozempic is around $997.58, which can be a significant financial burden for many seniors. However, under the new pilot program, beneficiaries could see their out-of-pocket costs drop to between $50 and $149 per month, making this medication more accessible.
Key Exceptions to Medicare Coverage Rules
Eligibility Criteria for Coverage
To qualify for coverage under the new pilot program, beneficiaries must meet specific eligibility criteria. This includes being overweight with an additional ailment such as diabetes, with a body mass index (BMI) of over 35, or a BMI of 27 with conditions like prediabetes or cardiovascular disease.
Participation Variability Among Plans
It’s important to note that not all Medicare Part D or Medicare Advantage plans will participate in the pilot program. Plans must opt-in, and beneficiaries will need to meet their plan’s deductibles while also having obesity with comorbidities to qualify for coverage.
Eligibility Requirements for Medicare Coverage
Who Can Access Coverage?
To access coverage for Ozempic, beneficiaries must be enrolled in a Medicare Part D standalone plan or a Medicare Advantage plan that includes drug coverage. Currently, only about 9% of adults aged 65 and older use GLP-1 medications, compared to 22% of those aged 50-64, largely due to these coverage limitations.
Recent Updates Impacting Medicare Coverage
New Developments in Drug Availability
The FDA has recently approved the first oral GLP-1 medication for weight loss, known as Wegovy, which is expected to be available in pharmacies by early January 2026. This development may further influence the landscape of weight-loss drug coverage under Medicare.
Changes in Coverage Structure
In December 2025, CMS announced a redesign of Medicare Part D that will require insurers to cover 60% of costs in catastrophic coverage, a significant increase from the previous 15%. This change may lead to higher premiums but is aimed at improving access to necessary medications.
Practical Tips for Navigating Medicare Coverage
Maximizing Your Medicare Benefits
To ensure you are getting the most out of your Medicare benefits, it’s crucial to check your Part D formulary for coverage details regarding Ozempic and similar medications. Utilizing the Medicare Plan Finder can help you navigate the options available for 2027 and understand your coverage specifics.
Resources for Assistance
If your Medicare plan does not cover necessary medications, financial assistance may be available. Additionally, taking advantage of the Medicare Annual Wellness Visit can provide an opportunity to discuss health concerns, including weight management, with your healthcare provider.
Understanding the Future of Ozempic Coverage Under Medicare
Currently, Medicare does not cover Ozempic for weight loss unless specific medical conditions are met. However, the upcoming CMS pilot program starting in 2026 may open new avenues for coverage, allowing beneficiaries to access this important medication under certain eligibility requirements.