Will Medicare Cover GLP-1 Drugs for Weight Loss?

No, Medicare will not cover GLP-1 drugs solely for weight loss purposes. On April 4, 2025, the Trump administration rejected a proposal from the Biden administration that would have reinterpreted Medicare rules to allow coverage of these medications specifically for obesity treatment.

This decision impacts millions of Medicare beneficiaries struggling with obesity who might have benefited from these effective but expensive medications. Medicare spending on GLP-1 drugs has already increased dramatically—from $57 million in 2018 to $5.7 billion in 2022—even with the current coverage limitations that only allow their use for specific conditions like diabetes.

If you're trying to access GLP-1 medications through Medicare, understanding the current rules, alternatives, and future possibilities can help you navigate your options. Let's explore what these medications are, how Medicare covers them currently, and what this means for beneficiaries seeking weight loss treatment.

Understanding GLP-1 Medications

GLP-1 receptor agonists represent a breakthrough class of medications that work by mimicking a hormone called glucagon-like peptide-1. This hormone helps regulate blood sugar, slows digestion, and reduces appetite by acting on receptors in the brain that control hunger and feelings of fullness.

Originally developed for diabetes management, these medications have proven remarkably effective for weight loss, helping patients lose an average of 12-15% of their body weight—significantly more than older weight loss medications that typically produced 5-10% weight loss.

The most popular GLP-1 medications include:

• Wegovy (semaglutide): FDA-approved for chronic weight management and reducing cardiovascular risk in certain patients
• Ozempic (semaglutide): Approved for type 2 diabetes management and cardiovascular risk reduction
• Zepbound (tirzepatide): Approved for chronic weight management and sleep apnea
• Mounjaro (tirzepatide): Approved for type 2 diabetes management

While Wegovy and Ozempic contain the same active ingredient (semaglutide), they have different FDA approvals and dosing. Similarly, Zepbound and Mounjaro both contain tirzepatide but are approved for different uses.

Current Medicare Coverage for GLP-1 Drugs

Medicare's stance on GLP-1 medications is governed by the Medicare Modernization Act of 2003, which specifically excludes coverage for drugs when used for weight loss. This exclusion was established when weight loss medications had limited effectiveness and significant safety concerns.

Currently, Medicare will only cover GLP-1 medications under the following circumstances:

1. For type 2 diabetes treatment: Drugs like Ozempic and Mounjaro are covered when prescribed for managing diabetes.
2. For cardiovascular disease risk reduction: Wegovy is covered for Medicare beneficiaries who have both cardiovascular disease and are overweight or have obesity.
3. For other FDA-approved indications: Zepbound can be covered for treating sleep apnea in qualifying patients.

Medicare will not cover these medications when prescribed solely for weight loss, regardless of a patient's BMI or obesity-related health complications.

The Policy Debate Over GLP-1 Coverage

The discussion around Medicare coverage of GLP-1 medications has evolved significantly as scientific understanding of obesity has changed. Unlike older weight loss drugs, GLP-1s have demonstrated both safety and remarkable effectiveness, causing many health policy experts to reconsider Medicare's exclusion.

In November 2024, the Biden administration proposed reinterpreting the statutory exclusion of weight loss drugs to allow Medicare coverage specifically for obesity treatment. This proposal would have expanded access to approximately 3.4 million Medicare beneficiaries with obesity.

However, on April 4, 2025, the Trump administration announced it would not implement this change, maintaining the existing policy that excludes coverage of these medications solely for weight loss. The decision was influenced by several factors, including:

• Cost concerns: The Congressional Budget Office estimated that covering these drugs would increase federal spending by $35.5 billion from 2026 to 2034.
• Budget implications: With GLP-1 medications costing $12,000-$16,000 annually per patient, widespread coverage could significantly impact Medicare's finances.
• Uncertain long-term benefits: While these medications show clear weight loss benefits, debates continue about whether the long-term health savings would offset the upfront medication costs.

Some healthcare experts argue that covering these medications could reduce costs associated with obesity-related conditions like heart disease, diabetes complications, and joint replacements. However, CBO analysis suggested these savings would be modest compared to the medication costs, at least in the near term.

Financial Impact of GLP-1 Medications

The high cost of GLP-1 medications represents a significant barrier for Medicare beneficiaries. Without insurance coverage, patients typically pay between $1,000 and $1,400 per month, amounting to $12,000-$16,000 annually.

These costs are substantially higher in the United States compared to other countries. For example, Ozempic costs between $83-$169 for a month's supply in countries like Canada, Australia, and European nations—significantly less than the U.S. list price of around $969.

Some relief may come through Medicare's drug price negotiation program established by the Inflation Reduction Act. Ozempic, Wegovy, and Rybelsus have been selected for the second round of Medicare price negotiations, with new prices taking effect in 2027. While this won't change Medicare's coverage policy for weight loss, it could reduce costs for those using these medications for covered indications.

If Medicare were to expand coverage to include weight loss, premiums for all Medicare Part D beneficiaries would likely increase to accommodate the additional costs. The Department of Health and Human Services estimated that providing this coverage would cost Medicare approximately $24.8 billion over ten years.

Alternative Access Options for GLP-1 Medications

Despite Medicare's restrictions, beneficiaries seeking GLP-1 medications for weight loss have several alternative options:

Medicare Advantage Supplemental Benefits: Some Medicare Advantage plans offer supplemental benefits beyond standard Medicare coverage. While they cannot directly cover GLP-1s for weight loss due to the statutory exclusion, some plans offer enhanced weight management programs that might include nutritional counseling and other services.

Manufacturer Savings Programs: Both Novo Nordisk (maker of Wegovy and Ozempic) and Eli Lilly (maker of Mounjaro and Zepbound) offer savings programs that can significantly reduce costs. However, most of these programs explicitly exclude Medicare beneficiaries due to federal anti-kickback regulations.

State Medicaid Programs: As of early 2025, approximately 15 states cover GLP-1 medications for obesity treatment through their Medicaid programs. Dual-eligible beneficiaries (those enrolled in both Medicare and Medicaid) in these states may have access through their Medicaid coverage.

Patient Assistance Programs: Some non-profit organizations and foundations provide financial assistance for medications. Eligibility is typically income-based, and availability of funds can be limited.

Cash-Pay Options: Some patients opt to pay out-of-pocket, particularly through direct-to-consumer pharmacy programs offered by manufacturers. These programs can reduce costs to around $500-$600 monthly, though this remains prohibitively expensive for many beneficiaries on fixed incomes.

Medicare Coverage Requirements for GLP-1s

For Medicare beneficiaries who qualify for GLP-1 coverage under approved indications, navigating the coverage requirements can be complex:

Documentation Requirements: Medicare typically requires comprehensive documentation including:

• Specific diagnosis codes matching approved indications
• Medical records demonstrating the necessity of the medication
• Evidence of previous treatments attempted
• For diabetes coverage, documentation of blood glucose levels and HbA1c results

Prior Authorization: Most Medicare Part D plans require prior authorization for GLP-1 medications, meaning the prescriber must get approval from the plan before the medication will be covered. This process can take several days to weeks.

Step Therapy: Many plans require patients to try less expensive medications first before approving GLP-1s, a process called step therapy. For diabetes, this might mean trying metformin before moving to a GLP-1.

Off-label Prescribing Limitations: While doctors can legally prescribe medications for off-label uses, Medicare Part D plans generally will not cover medications prescribed outside their FDA-approved indications. This means that even if your doctor prescribes Ozempic for weight loss, Medicare won't cover it for that purpose.

Looking Ahead: Future GLP-1 Coverage Proposals

Though Medicare won't cover GLP-1s for weight loss in 2026, several policy proposals could change this situation in the future:

The Treat and Reduce Obesity Act: This bipartisan legislation has been introduced in multiple sessions of Congress. If passed, it would remove the statutory exclusion of weight loss medications from Medicare coverage. The most recent version was marked up by the House Committee on Ways and Means in June 2024.

Limited Coverage Proposals: Some policymakers have suggested more limited approaches, such as covering GLP-1s only for beneficiaries who had coverage for these drugs from a non-Medicare plan in the year before enrolling in Medicare. This would cost significantly less than full coverage while helping those already stabilized on treatment.

Ongoing Clinical Research: As more research emerges about the long-term health benefits of GLP-1 medications, particularly their impact on conditions like cardiovascular disease, Medicare may reconsider its stance based on potential healthcare savings.

Administrative Reconsideration: While the Trump administration chose not to implement the coverage change in 2025, they did not rule out reconsidering the policy in the future as more data becomes available on both costs and benefits.

The political landscape after the 2026 midterm elections may also influence whether this issue is revisited, as healthcare priorities often shift with changes in congressional and administrative leadership.

How a Solace Advocate Can Help with GLP-1 Access

Navigating the complexities of Medicare coverage for GLP-1 medications can be overwhelming. A Solace health advocate can provide valuable assistance in several ways:

Exploring Coverage Options: A Solace advocate can help determine if you qualify for GLP-1 coverage under existing Medicare rules based on your specific medical conditions, reviewing whether you meet criteria for diabetes, cardiovascular disease, or sleep apnea coverage.

Finding Alternative Access Programs: Advocates can research and connect you with manufacturer assistance programs, foundation support, and other resources that might help reduce out-of-pocket costs for GLP-1 medications.

Documentation Support: If you do qualify for coverage, a Solace advocate can help ensure your medical records contain the proper documentation to support your case, working with your healthcare providers to compile necessary information for prior authorizations.

Appeal Assistance: If your coverage request is denied, an advocate can guide you through the appeals process, helping prepare the necessary documentation and following up with Medicare or your Part D plan.

Clinical Trial Opportunities: Advocates can research ongoing clinical trials involving GLP-1 medications that might provide access to these treatments at reduced or no cost while contributing to medical research.

Coordination Between Specialists: Managing weight often requires a team approach. A Solace advocate can help coordinate communication between your primary care physician, endocrinologist, cardiologist, and other specialists to ensure a comprehensive treatment approach.

Medication Education: Advocates can provide information about potential side effects, drug interactions, and proper administration of GLP-1 medications to maximize benefits and minimize complications.

Alternative Treatment Options: If GLP-1 medications remain inaccessible, advocates can help explore Medicare-covered alternatives for weight management, including nutritional therapy, behavioral counseling, and in some cases, bariatric surgery.

Frequently Asked Questions about Medicare and GLP-1 Drugs

Will Medicare pay for Wegovy if I have heart disease?

Yes, Medicare will cover Wegovy if you have established cardiovascular disease and are also overweight or have obesity. This coverage is based on the FDA's approval of Wegovy for reducing cardiovascular risk in this specific patient population, not for weight loss alone.

Is Ozempic the same as Wegovy?

Ozempic and Wegovy both contain the same active ingredient (semaglutide), but they are different FDA-approved products with different dosing regimens. Ozempic is approved for type 2 diabetes and cardiovascular risk reduction, while Wegovy is approved for chronic weight management and cardiovascular risk reduction in certain patients.

Can my doctor prescribe a GLP-1 drug off-label for weight loss under Medicare?

While doctors can legally prescribe medications for off-label uses, Medicare Part D plans will not cover GLP-1 medications when prescribed solely for weight loss. If you receive an off-label prescription, you would likely need to pay the full cost out-of-pocket.

What documentation do I need to get a GLP-1 covered for diabetes?‍

For diabetes coverage, you'll typically need documentation of your diagnosis including lab results (like HbA1c levels), records of previous diabetes treatments, and sometimes proof that you've tried other medications first. Your doctor must certify that the GLP-1 medication is medically necessary for your diabetes management.

How much would I pay out-of-pocket for a GLP-1 medication with Medicare Part D?‍

With Medicare Part D coverage for approved indications, the average out-of-pocket cost for GLP-1 medications in 2023 was about $60 for a one-month supply, with annual costs averaging around $391. However, costs vary significantly based on your specific plan, whether you're receiving low-income subsidies, and which phase of coverage you're in (deductible, initial coverage, coverage gap, or catastrophic coverage).

‍

‍