Excess weight can cause secondary health issues to occur, but it can be difficult to lose weight with exercise and diet alone. While medications have been developed to help people lose weight, they may not be suitable for every person. Understanding how they work and any potential risks involved with taking them can help Medicare recipients make an informed decision.
Medicare’s complex rules around weight loss medications leave millions of beneficiaries confused about what’s actually covered. While most weight loss drugs are excluded, there are surprising loopholes and upcoming changes that could save you thousands in 2025.
Key Takeaways
- Medicare Part D excludes drugs used solely for weight loss, but coverage may be available for medications with FDA-approved medical uses beyond weight management
- GLP-1 drugs like Ozempic and Mounjaro can be covered for Type 2 diabetes, while Wegovy may be covered for cardiovascular risk reduction in qualifying patients
- Medicare Part B covers obesity counseling and behavioral therapy for beneficiaries with a BMI of 30 or higher when provided in primary care settings
- The 2025 Medicare Part D changes cap annual out-of-pocket costs at $2,000 for covered medications, significantly reducing patient expenses
- New pilot programs could potentially expand Medicare coverage for weight loss drugs starting as early as 2027
Medicare’s approach to weight loss medications creates confusion for millions of beneficiaries seeking help with weight management. While federal regulations prohibit coverage for drugs used solely for weight loss, there are important exceptions and alternative coverage options that many people don’t know about.
Medicare Generally Excludes Weight Loss Drugs, but FDA-Approved Medical Uses May Qualify
Federal law specifically prohibits Medicare Part D plans from covering medications prescribed solely for weight loss purposes. This exclusion dates back to the Medicare Modernization Act of 2003, which created the Part D prescription benefit while explicitly excluding coverage for drugs “used for anorexia, weight loss, or weight gain.”
However, this exclusion doesn’t apply when weight loss medications have FDA-approved indications for other medical conditions. The key distinction lies in the primary purpose of the prescription—if a doctor prescribes the medication to treat diabetes, cardiovascular disease, or sleep apnea rather than weight loss alone, Medicare may provide coverage.
For detailed information about Medicare coverage options for weight loss medications, guidance is available to help beneficiaries understand their specific plan benefits and requirements.
When Weight Loss Medications Get Medicare Part D Coverage
Three primary categories of weight loss medications may qualify for Medicare Part D coverage when prescribed for approved medical indications rather than weight management alone.
1. GLP-1 Drugs for Type 2 Diabetes Management
Popular GLP-1 receptor agonists like Ozempic (semaglutide), Mounjaro (tirzepatide), and Trulicity (dulaglutide) receive Medicare coverage when prescribed for Type 2 diabetes management. These medications help control blood sugar levels while often producing weight loss as a secondary benefit. Medicare Part D plans typically cover these drugs on their formularies, though prior authorization requirements and step therapy protocols may apply depending on the specific plan.
2. Wegovy for Cardiovascular Risk Reduction
Wegovy (semaglutide) gained FDA approval for reducing cardiovascular death, heart attack, and stroke risk in adults with established cardiovascular disease who are overweight or obese. This indication allows Medicare Part D plans to cover Wegovy when prescribed specifically for cardiovascular protection rather than weight loss. Patients must have documented cardiovascular disease and meet specific BMI criteria to qualify for coverage under this indication.
3. Zepbound for Obstructive Sleep Apnea
Zepbound (tirzepatide) received FDA approval for treating moderate to severe obstructive sleep apnea in adults with obesity. This medical indication enables potential Medicare coverage when the medication is prescribed to address sleep apnea rather than weight management. Coverage requires proper documentation of sleep study results and obesity-related sleep apnea diagnosis.
How Medicare Part D Drug Coverage Works in 2025
Significant changes to Medicare Part D in 2025 improve affordability for beneficiaries requiring expensive medications, including qualifying weight loss drugs.
$2,000 Annual Cap Changes Your Out-of-Pocket Costs
The Inflation Reduction Act established a $2,000 annual out-of-pocket maximum for Medicare Part D prescription drugs in 2025. This cap applies to all covered medications, meaning beneficiaries pay nothing for covered prescriptions after reaching the $2,000 threshold. For expensive GLP-1 medications that may cost $1,000 or more monthly, this cap provides substantial financial protection.
Before reaching the cap, beneficiaries typically pay 25% coinsurance for covered drugs after meeting their plan’s deductible. High-cost specialty medications often fall on higher formulary tiers with coinsurance rates between 25% and 33%, depending on the plan’s deductible structure.
Prior Authorization and Step Therapy Requirements
Most Medicare Part D plans require prior authorization for expensive weight loss medications, even when prescribed for covered indications. The prior authorization process requires doctors to submit medical documentation proving the medication is medically necessary for the approved indication, not weight loss.
Step therapy requirements may mandate trying less expensive alternatives first. For diabetes management, plans often require attempting metformin or other first-line treatments before approving GLP-1 medications. Documentation of treatment failure or contraindications to preferred medications supports approval requests.
Coverage varies by plan type, so it’s important to review your Medicare Advantage plan options to see which formularies include these drugs. Some Medicare Special Needs plans are starting to cover these drugs, as well. And the SNP options are growing.
Medicare-Covered Weight Management Services Beyond Medications
Even when prescription weight loss drugs aren’t covered, Medicare provides several weight management services that support healthy weight goals.
Part B Obesity Counseling and Behavioral Therapy
Medicare Part B covers Intensive Behavioral Therapy (IBT) for obesity screening and counseling when beneficiaries have a BMI of 30 or higher. This benefit includes up to 22 face-to-face visits annually when provided by qualified primary care practitioners in primary care settings.
IBT services include BMI screening, dietary assessment, and intensive counseling on diet and exercise modifications. The service requires no copayment, coinsurance, or deductible when provided by Medicare-approved practitioners. This coverage began in 2011 when the Centers for Medicare & Medicaid Services implemented specific coding for IBT to encourage healthcare professional utilization.
Medical Nutrition Therapy and Bariatric Surgery Coverage
Medicare covers Medical Nutrition Therapy (MNT) for beneficiaries with diabetes or kidney disease when referred by a physician. MNT includes nutritional diagnostic, therapy, and counseling services provided by registered dietitians.
Bariatric surgery receives Medicare coverage when medically necessary for severe obesity. Beneficiaries must have a BMI of 35 or higher plus at least one obesity-related health condition, such as diabetes, high blood pressure, or sleep apnea. The surgery must be performed at Medicare-approved facilities by qualified surgeons.
Managing Costs When Medicare Doesn’t Cover Your Weight Loss Drug
When Medicare doesn’t provide coverage for weight loss medications, several strategies can help manage the substantial costs.
Out-of-Pocket Prices Drop to $499 Monthly with Discounts
Pharmaceutical manufacturers have introduced significant price reductions for cash-paying patients. Both Novo Nordisk and Eli Lilly now offer their weight loss medications at $499 per month for people paying out-of-pocket. This represents a substantial reduction from typical retail prices that can exceed $1,200 monthly.
Wegovy is available through NovoCare Pharmacy at the $499 price point with home delivery options. Similarly, discount programs through GoodRx and other prescription savings platforms can reduce costs to comparable levels, making these medications more accessible to Medicare beneficiaries.
Patient Assistance Programs and HSA/FSA Options
Manufacturer patient assistance programs provide additional cost relief for qualifying individuals. These programs typically require income verification and may offer free or reduced-price medications for eligible patients.
Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) can be used to pay for qualifying weight loss medications with pre-tax dollars. HSA funds roll over annually and never expire, while FSA funds must be used within the plan year or forfeit unused balances.
Future Medicare Coverage Could Start by 2027 Under New Pilot Program
The Centers for Medicare & Medicaid Services is testing pilot programs that could allow Medicare Part D plans to cover GLP-1 drugs specifically for weight management. This experimental approach could begin as early as 2027, representing a significant policy shift from current exclusions.
The proposed pilot program would test coverage models in selected states or regions, evaluating both clinical outcomes and cost-effectiveness. If successful, these pilots could lead to broader Medicare coverage for weight loss medications, potentially expanding access for millions of beneficiaries.
Current legislation, including the proposed Treat and Reduce Obesity Act, seeks to reclassify obesity as a disease rather than a cosmetic condition, which would remove barriers to Medicare coverage. The American Medical Association’s 2013 declaration of obesity as a disease provides medical foundation for these policy changes.