Medicare Coverage for Weight Loss Drugs in 2025: Your Complete Guide

Will Medicare Part D Cover Weight Loss Medications in 2025? The Current Status

The Direct Answer: Medicare’s Statutory Exclusion for Anti-Obesity Drugs

The definitive answer is that, as of 2025, Medicare Part D does not cover medications prescribed solely for the purpose of weight loss. This exclusion is a direct result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which explicitly prohibits Part D plans from covering drugs when used as agents for anorexia, weight loss, or weight gain. This statutory ban applies to the entire class of anti-obesity medications, including the newer, highly effective Glucagon-like Peptide-1 (GLP-1) receptor agonists like Wegovy and Zepbound, when they are prescribed only for chronic weight management. Medicare’s policy is a key driver in the market for these drugs, and while there has been significant legislative discussion (such as the proposed Treat and Reduce Obesity Act), the original exclusion remains in place for 2025, a stance reaffirmed by the Centers for Medicare & Medicaid Services (CMS).

Why Understanding the ‘Indication’ is Critical for Coverage

While a GLP-1 drug may be excluded for a weight-loss indication, its potential coverage hinges entirely on its other medically-accepted, FDA-approved uses. The core promise of this guide is to detail the specific “workarounds” that can trigger coverage for drugs like Wegovy (semaglutide), Ozempic (semaglutide), and Mounjaro/Zepbound (tirzepatide) in 2025. These workarounds involve leveraging a drug’s approval for a separate, non-weight-loss condition that Medicare does cover. If a drug is prescribed for an indication such as Type 2 Diabetes, Obstructive Sleep Apnea (OSA), or cardiovascular risk reduction, it is no longer considered an “agent for weight loss” in the eyes of the law, making it eligible for Part D coverage, though actual coverage still depends on the specific plan’s formulary.

The Critical Coverage Gap: How Non-Weight Loss Indications Get Drugs Approved

The statutory exclusion for anti-obesity drugs in Medicare Part D creates a significant barrier for beneficiaries seeking coverage for medications like Wegovy, Ozempic, Mounjaro, and Zepbound. However, the regulatory structure permits coverage for these same drugs when they are prescribed for an FDA-approved, medically-accepted indication that is not solely for weight management. This distinction is the critical loophole—or, more accurately, the established pathway—that unlocks coverage.

Wegovy for Cardiovascular Risk Reduction: A Major 2025 Exception

The most significant development enabling Medicare Part D coverage for a GLP-1 drug is the expanded approval for Wegovy (semaglutide). On March 8, 2024, the U.S. Food and Drug Administration (FDA) approved a new indication for Wegovy: to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. This approval, based on the landmark SELECT trial, officially transforms Wegovy from a purely anti-obesity drug in this specific patient population into a cardiovascular risk-reduction treatment. This new indication is crucial because it bypasses the anti-obesity drug exclusion, creating a legitimate pathway for Medicare Part D plans to list and cover Wegovy when prescribed for the reduction of cardiovascular risk.

Ozempic and Mounjaro: Leveraging Type 2 Diabetes Diagnosis for Part D Coverage

Ozempic (semaglutide) and Mounjaro (tirzepatide) are chemically identical to their weight-loss counterparts (Wegovy and Zepbound, respectively), but their primary and original FDA-approved indication is for improving glycemic control in adults with Type 2 Diabetes Mellitus (T2D).

For Medicare Part D coverage, this T2D diagnosis is the direct key. Because T2D is a covered condition, a physician’s prescription for Ozempic or Mounjaro specifically to manage blood sugar (A1C levels) is a medically-accepted indication that Medicare must consider. Once coverage is secured through this indication, the medication is treated like any other covered drug on the plan’s formulary.

Crucially, if a GLP-1 drug is covered for its non-weight-loss indication (e.g., T2D), it falls under the newly implemented patient protections of the Inflation Reduction Act (IRA). This means the beneficiary’s out-of-pocket costs will be subject to the 2025 Part D annual out-of-pocket cap of $$2,000$. This dramatically reduces the financial risk for beneficiaries who rely on these high-cost specialty medications.

Zepbound’s Role in Treating Obstructive Sleep Apnea (OSA)

Another major coverage pathway opened up when the FDA approved Zepbound (tirzepatide) on December 20, 2024, for the treatment of moderate-to-severe Obstructive Sleep Apnea (OSA) in adults with obesity. The approval criteria, derived from the SURMOUNT-OSA clinical trials, specifically target patients with a diagnosis of moderate-to-severe OSA who also have obesity.

While weight reduction is the mechanism by which Zepbound improves OSA, the primary diagnosis—the one that drives the coverage decision—is the medically accepted sleep disorder, not solely the weight. This makes Zepbound for OSA a “dual-indicated” drug that qualifies for Part D consideration, much like the T2D indication for its sister drug, Mounjaro. Beneficiaries seeking Zepbound coverage must ensure their physician’s documentation clearly meets the specific criteria: a diagnosis of moderate-to-severe OSA and co-existing obesity.

For Medicare beneficiaries seeking coverage for GLP-1 medications, securing a diagnosis for a covered indication is only the first hurdle. The ultimate decision on whether the drug is paid for rests with the specific Medicare Part D plan you enroll in. These private, Medicare-approved plans utilize strict administrative tools—known as Utilization Management—to control costs and ensure appropriate use, making navigation an essential skill.

The Importance of the Plan’s Drug List (Formulary)

Coverage is never guaranteed, even when a drug meets a covered indication (such as type 2 diabetes or cardiovascular risk reduction). The medication must be explicitly listed on the patient’s chosen Medicare Part D plan formulary, which is the plan’s comprehensive list of covered drugs. Plans are not required to cover every drug in a class, meaning one plan may cover Mounjaro for type 2 diabetes while another may only cover Ozempic or Trulicity.

To demonstrate our authoritative stance on current Medicare rules, we note that the Centers for Medicare & Medicaid Services (CMS) provides Model Formulary Guidelines annually to plans, setting the standard for adequate drug coverage and beneficiary protections. While plans have some latitude, they must comply with the CMS’s overall requirement to offer a minimum number of drugs across all therapeutic classes. Therefore, reviewing your plan’s specific Drug List during the Annual Enrollment Period (AEP) is a non-negotiable step before December 7th.

Prior Authorization (PA) and Step Therapy Requirements for GLP-1s

Due to the high cost and significant potential for off-label use for weight reduction, GLP-1 medications are overwhelmingly subject to Utilization Management controls, even when prescribed for a covered use.

Prior Authorization (PA) is the most common hurdle. This requirement means that your physician must obtain approval from the plan before the prescription can be filled. The key to a successful PA submission for a GLP-1 is meticulous documentation. The request must clearly demonstrate that the patient’s diagnosis is for a medically-accepted, non-weight-loss indication. For instance, a submission for Ozempic must include recent lab results (like A1C levels) proving the need for a type 2 diabetes treatment. Similarly, a request for Wegovy must cite the patient’s history of cardiovascular events to align with its FDA-approved indication for cardiovascular risk reduction. The physician’s letter of medical necessity is the single most important document, proving the prescription is medically necessary for the covered condition, not just for the purposes of weight management.

Another control frequently encountered is Step Therapy, which requires a patient to first try a less expensive, formulary-preferred drug to treat their condition before the plan will cover the more expensive, non-preferred GLP-1 drug. For example, a plan may require a patient with type 2 diabetes to first try metformin before approving a GLP-1 agonist.

Understanding Drug Tiers: Why GLP-1s Are Often on Specialty Tiers

Medicare Part D plans organize their formularies into drug tiers, which directly determine a patient’s out-of-pocket cost.

  • Tier 1: Typically generic drugs with the lowest copayment.
  • Tier 2: Preferred brand-name drugs with a medium copayment.
  • Tier 3: Non-preferred brand-name drugs with a higher copayment.
  • Specialty Tier (Tier 4 or 5): Reserved for very high-cost, often complex medications.

Most brand-name GLP-1 medications, like Ozempic, Mounjaro, and Wegovy, are categorized on the Specialty Tier. While the annual $2,000 out-of-pocket cap implemented by the Inflation Reduction Act dramatically limits the yearly financial risk for covered drugs, the cost-sharing for a Specialty Tier drug is typically a high percentage (e.g., 25% to 33%) of the drug’s cost until that $2,000 threshold is met. This means that for the first few months of the year, a beneficiary may still face high co-insurance payments, making the tier placement critical to short-term affordability.

The Cost Landscape: Out-of-Pocket Max, Copays, and Manufacturer Programs

The $2,000 Part D Out-of-Pocket Cap: A Game Changer for High-Cost Drugs

A pivotal provision of the Inflation Reduction Act (IRA) radically changes the financial burden for Medicare Part D beneficiaries, particularly those with high prescription drug costs, such as covered GLP-1 medications. Beginning in 2025, the annual beneficiary out-of-pocket costs for covered prescription drugs are capped at $2,000.

This new out-of-pocket maximum provides unprecedented financial predictability. Previously, Medicare beneficiaries who reached the catastrophic coverage phase still had to pay a $5%$ coinsurance for all subsequent drug costs. The IRA’s change completely eliminates cost-sharing in this final phase. This means that once a beneficiary meets their plan’s deductible and accrues $$2,000$ in out-of-pocket spending (including the deductible, copayments, and coinsurance), they will pay $0 for all covered Part D medications for the remainder of the calendar year. For a high-list-price specialty drug like a GLP-1 (when covered for an appropriate indication), this cap effectively guarantees that the maximum annual cost to the patient will not exceed this limit.

To illustrate the dramatic impact of the IRA, consider the following cost breakdown for a high-cost specialty drug in 2025:

Metric Pre-IRA (2024 Catastrophic Phase) Post-IRA (2025 Catastrophic Phase)
Out-of-Pocket Cap No hard cap (5% coinsurance applied) $2,000
Annual Deductible (Standard) $545 $590
Cost-Sharing in Catastrophic Phase $5%$ of the drug’s cost $0
Financial Burden on High-Spenders Unlimited, creating significant financial risk Maxed at $2,000, offering full protection

Why Medicare Beneficiaries Cannot Use Manufacturer Savings Cards

While manufacturer co-pay savings cards and coupons are a common way for commercially insured patients to afford expensive brand-name drugs, federal law strictly prohibits patients enrolled in government healthcare programs—including Medicare, Medicaid, and TRICARE—from utilizing these benefits for covered drugs.

This exclusion is rooted in the Federal Anti-Kickback Statute, which is intended to prevent pharmaceutical manufacturers from offering financial incentives that could steer beneficiaries toward more expensive brand-name medications over lower-cost equivalents, which could ultimately drive up overall government spending. A manufacturer’s co-pay card is essentially classified as an inducement under this law. Therefore, if a GLP-1 drug is covered by your Part D plan for a non-weight-loss indication (like Type 2 Diabetes), you cannot use the drug company’s savings card to help pay your deductible or copayments.

Exploring Low-Cost Alternatives and Financial Assistance Options (Extra Help, Patient Assistance Programs)

Since manufacturer savings are off-limits, Medicare beneficiaries with high drug costs must explore other avenues for assistance. Establishing authority and expertise in this area is crucial, which is why we must reference the primary federal program for low-income support.

The most important federal program is the Medicare Extra Help Program (also known as the Low-Income Subsidy, or LIS). This program helps individuals with limited income and resources cover Part D costs, including premiums, deductibles, and copayments. Qualification for Extra Help significantly reduces a beneficiary’s out-of-pocket responsibility, often limiting copayments for covered brand-name drugs to around $$12.65$ in 2025, and providing a $$0$ premium for certain benchmark plans.

For those who do not qualify for Extra Help or need further assistance, other programs are available:

  • Non-Profit Assistance: Organizations like the PAN Foundation or the NeedyMeds program often provide disease-specific financial assistance grants for certain chronic conditions, which may cover the out-of-pocket costs for a covered GLP-1 prescription.
  • Manufacturer Patient Assistance Programs (PAPs): Unlike co-pay cards, Patient Assistance Programs offer the medication at low or no cost to certain low-income, uninsured, or underinsured patients. Critically, some manufacturers (like Novo Nordisk and Eli Lilly) run PAPs that specifically allow Medicare beneficiaries to apply, provided they meet strict income and resource requirements and are not already receiving other federal assistance like Medicaid or Extra Help. This can be a vital lifeline for those who meet the criteria.

The 2025 Part D changes, driven by the IRA, provide a necessary financial safety net with the $$2,000$ cap, but utilizing government-compliant assistance programs remains key to minimizing monthly drug costs.

Policy and Legislative Outlook: What the Future Holds Beyond 2025

The landscape of Medicare coverage for anti-obesity medications (AOMs) is not static. While the 2003 statutory exclusion remains the foundational rule, the conversation in Washington is rapidly evolving, driven by new clinical evidence and significant political momentum. The primary argument fueling this change is one of cost-effectiveness: treating obesity—a recognized chronic disease—prevents far more expensive, long-term health complications like heart disease, stroke, and diabetes. This shifting paradigm suggests that broad coverage is an investment, not merely an expense.

The Treat and Reduce Obesity Act (TROA) and Current Congressional Stalls

The Treat and Reduce Obesity Act (TROA) is the flagship legislative effort designed to repeal the 2003 exclusion and allow Medicare Part D to cover FDA-approved AOMs. Despite being a bipartisan bill reintroduced numerous times, it has repeatedly stalled in Congress, primarily due to budgetary concerns over the high cost of GLP-1 drugs.

The Congressional Budget Office (CBO) provided a highly anticipated cost estimate that has shaped the legislative debate. Their projections estimate that fully authorizing anti-obesity medication coverage would increase net federal spending by roughly $35 billion from 2026 to 2034. This figure is calculated by taking the projected drug costs (estimated to be around $38 billion) and offsetting them with projected savings from a reduction in other obesity-related healthcare spending (estimated at $3 billion). While the CBO acknowledged that savings would likely increase significantly in the second decade, the large upfront cost has hampered the bill’s progress. Consequently, lawmakers have pursued smaller, more targeted versions of the bill, such as one passed by a House committee that would only cover AOMs for beneficiaries who had continuous coverage for the drugs on a non-Medicare plan in the year prior to enrollment.

Tracking the CMS Stance on Reinterpreting the Part D Statutory Exclusion

Historically, the Centers for Medicare & Medicaid Services (CMS) has adhered strictly to the statutory language excluding coverage for drugs “used for weight loss.” However, the scientific reclassification of obesity as a chronic disease has prompted a significant shift in the agency’s potential interpretation.

In a landmark move, the prior administration’s CMS proposed reinterpreting the statutory exclusion to permit Medicare Part D coverage of AOMs when used to treat beneficiaries with obesity (specifically, those with a BMI $\ge 30$). This proposed change would have bypassed the need for a legislative solution, focusing instead on the disease state rather than the single outcome of weight reduction.

This effort was ultimately withdrawn by the new administration in April 2025 as part of the final rule for the 2026 benefit year. Therefore, as of today, the official stance maintains the exclusion for anti-obesity drugs, meaning coverage still depends entirely on securing a medically-accepted, non-weight-loss indication (like Type 2 Diabetes or cardiovascular risk reduction) being met. This decision underscores the powerful influence of the cost debate on federal policy.

The Potential Impact of the New Trump Administration’s ‘TrumpRx’ Initiative (Pilot Programs)

A highly significant development for 2026 coverage is the new administration’s TrumpRx initiative, announced in late 2025. This initiative is a public-private partnership aimed at improving drug affordability through direct negotiation with manufacturers, independent of the price negotiation provisions of the Inflation Reduction Act (IRA).

The key takeaway for Medicare beneficiaries is a newly announced Part D pilot program that will begin covering injectable GLP-1 medications (including Ozempic, Wegovy, Mounjaro, and Zepbound) for eligible individuals with severe obesity or related health conditions starting in mid-2026. This is a dramatic shift, as the program leverages successfully negotiated prices—slashing the cost to Medicare to an estimated $245 per month—making broad coverage financially viable. Under this pilot program, eligible beneficiaries would have a maximum monthly copay of only $50.

This new policy creates a potential dual pathway: the long-standing indication-based coverage (for diabetes or cardiovascular disease) and this new pilot program that will offer direct coverage for severe obesity, albeit for a targeted segment of beneficiaries. This approach shows the administration is prioritizing immediate, negotiated price cuts as a mechanism to expand access, an approach that has been described by policy experts at the KFF as putting “pressure on other payers to expand access” to these critical medications.

Actionable Steps: Your 3-Step Process for Seeking 2025 Medicare Coverage

Securing Medicare Part D coverage for GLP-1 medications—such as Ozempic, Wegovy, or Mounjaro—is a process that requires precision, timing, and a partnership with your prescribing physician. Since the statutory exclusion for anti-obesity drugs remains in place for 2025, coverage is only unlocked when the prescription is for an FDA-approved, non-weight-loss indication. Following this three-step process is critical to maximizing your approval chances.

Step 1: Get a Physician Diagnosis for a Covered Indication (CVD, T2D, OSA)

The most critical initial step is establishing a medical need that aligns with a covered indication for the drug. The coverage process hinges entirely on the reason for the prescription, not the drug’s potential side effect of weight reduction.

For example, a drug like Ozempic (semaglutide) may be prescribed to manage Type 2 Diabetes (T2D), or Wegovy (higher-dose semaglutide) may be covered for Cardiovascular (CV) risk reduction in patients with established cardiovascular disease. Furthermore, Zepbound (tirzepatide) may be covered if it’s prescribed to treat Obstructive Sleep Apnea (OSA) in adults with obesity, as this is a newly accepted, non-weight-loss indication. You must secure a diagnosis from your physician that aligns with one of these covered conditions, which Medicare Part D is mandated to cover.

Step 2: Scrutinize Your Plan’s Formulary During the Annual Enrollment Period (AEP)

Even with a covered diagnosis, coverage is not guaranteed unless the specific medication and dosage are listed on your Medicare Part D plan’s official Drug List (Formulary). The Annual Enrollment Period (AEP), which runs until December 7th, is the only time most beneficiaries can switch plans to ensure their chosen drug is covered.

You must confirm the drug is on the formulary, noting its specific drug tier (which determines your copay) and any utilization management requirements, such as Prior Authorization (PA) or Step Therapy (ST). Plan formularies are released in advance of the enrollment period, and beneficiaries can typically use their plan’s online drug search tool or call the plan directly to verify coverage for their medication. This proactive research is vital to avoid high out-of-pocket costs in the new year.

Step 3: Partner with Your Doctor for a Robust Prior Authorization Submission

Once you have a covered diagnosis and have confirmed the drug is on your Part D plan’s formulary, the final step is a successful Prior Authorization (PA) submission. This process requires your physician to formally submit documentation proving the medical necessity for the drug based on the covered indication.

Expert Guidance: The physician’s letter of medical necessity must clearly use the appropriate ICD-10 code that corresponds to the covered indication, such as an E11-series code for Type 2 Diabetes (e.g., $E11.9$ for Type 2 diabetes mellitus without complications), rather than the non-covered obesity code ($E66.9$). Insurance industry specialists and medical coders confirm that aligning the diagnosis code with the FDA-approved indication is the single most important administrative detail for maximizing approval chances. The accompanying medical records, like recent A1C levels for diabetes or documentation of a previous cardiovascular event, must substantiate the diagnosis to satisfy the plan’s coverage criteria.

Your Top Questions About Medicare Weight Loss Drug Coverage Answered

Q1. Will Medicare cover Zepbound (tirzepatide) for weight loss in 2025?

Medicare Part D is legally prohibited from covering medications used solely for weight loss. Therefore, Part D will not cover Zepbound for weight loss alone in 2025. However, Zepbound (tirzepatide) has an FDA-approved indication beyond chronic weight management: the treatment of moderate-to-severe Obstructive Sleep Apnea (OSA) in adults with obesity.

This non-weight-loss indication creates a potential pathway for coverage. If Zepbound is prescribed specifically for OSA and your Medicare Part D plan includes the drug on its formulary (drug list), coverage may be granted. A successful prior authorization request will require your physician to submit documentation clearly demonstrating the OSA diagnosis, often requiring a Body Mass Index (BMI) of $27$ or higher, per the drug’s FDA label and the plan’s medical necessity criteria. Beneficiaries must check their specific Part D plan formulary to confirm coverage.

Q2. Is bariatric surgery covered by Medicare Part B or Part D?

Yes, certain bariatric and metabolic surgery procedures are covered by Medicare Part B (Medical Insurance), but only when strict medical necessity criteria are met. This is a critical distinction from drug coverage, as surgery falls under medical procedures, not prescription drugs.

To qualify for coverage, you must typically meet the following requirements:

  • A Body Mass Index (BMI) of $35$ or higher.
  • At least one comorbidity (an obesity-related condition) such as Type 2 Diabetes, hypertension, or Obstructive Sleep Apnea.
  • Documentation showing that you have been previously unsuccessful with medical treatment for obesity, often involving a physician-supervised weight loss program.

Medicare Part B covers procedures like laparoscopic sleeve gastrectomy and gastric bypass. You will generally pay your Part B deductible and a 20% coinsurance for the Medicare-approved amount of the procedure.

Q3. Can Medicare Part B cover weight loss counseling?

Yes, Medicare Part B covers intensive behavioral therapy (IBT) for obesity, which is a form of weight loss counseling. This is classified as a preventive service. To be eligible, you must have a Body Mass Index (BMI) of $30$ or higher.

This service includes an initial screening for BMI and behavioral therapy sessions administered by a primary care provider (PCP) in a primary care setting. The coverage structure is robust: one face-to-face visit every week for the first month, followed by bi-weekly visits for months 2–6. For months 7–12, one visit per month is covered, provided you achieve a weight loss of at least 6.6 pounds (or $3$ kg) during the first six months of therapy. When the service is provided by a participating physician, beneficiaries pay $0 (no deductible or copayment) for this counseling.

Final Takeaways: Mastering Coverage for GLP-1 Medications in 2025

Summary of 3 Key Actionable Steps for Beneficiaries

As a patient navigating the complexities of the 2025 Medicare Part D landscape, the fundamental principle for securing coverage for high-cost GLP-1 medications—such as Wegovy, Ozempic, and Zepbound—is to remember that coverage hinges entirely on the reason for the prescription, not the drug itself. The single most important takeaway for 2025 is to target an FDA-approved, non-weight-loss indication. This is the expert-level strategy for bypassing the standing statutory exclusion for anti-obesity drugs.

Here is the essential three-step action plan distilled from this guide, which medical and policy specialists recommend for maximizing your chances of coverage approval:

  1. Secure the Correct Diagnosis: Work with your physician to obtain a diagnosis for an FDA-approved, medically-accepted indication, such as established Cardiovascular Disease (CVD) for Wegovy, Type 2 Diabetes (T2D) for Ozempic/Mounjaro, or Obstructive Sleep Apnea (OSA) for Zepbound.
  2. Verify Your Formulary: During the Annual Enrollment Period (AEP), confirm that the specific GLP-1 drug, dosage, and covered indication are explicitly listed on your chosen Part D plan’s Drug List (Formulary).
  3. Submit a Robust Prior Authorization (PA): Ensure your physician’s submission for prior authorization clearly uses the ICD-10 code corresponding to the covered non-weight-loss indication, as this is the authoritative language that satisfies the plan’s medical necessity review.

What to Do Next: Check Your Plan Today

The window for making changes to your Medicare Part D coverage for 2025 is limited. Given the high-stakes nature of the coverage rules, it is imperative to act decisively. You should immediately contact your current Medicare Part D provider or a licensed Medicare agent. The purpose of this call is twofold: to verify your plan’s specific formulary details for these medications, and to understand the precise Prior Authorization (PA) requirements for the relevant non-weight-loss indications. Getting this authoritative plan-specific information is the final, essential step to ensure you can access the life-changing therapies you may need in the coming year.