Medicare Coverage for Weight Loss Drugs: A Comprehensive 2026 Guide

Understanding Medicare Coverage for GLP-1 Weight Loss Medications

The Direct Answer: Does Medicare Part D Cover Weight Loss Drugs?

The simple answer, under current law, is no—Medicare Part D is legally prohibited from covering drugs prescribed solely for the purpose of weight loss. This limitation stems from a statutory exclusion in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which explicitly bans Part D plans from covering agents used for anorexia, weight loss, or weight gain.

However, the situation is complex and dynamic. The key to potential coverage lies in the specific reason your doctor prescribes the medication, known as the medically accepted indication. Coverage becomes possible if a drug, such as a GLP-1 agonist, is prescribed for a separate, FDA-approved condition like Type 2 diabetes, or for reducing the risk of a major cardiovascular event (heart attack or stroke). In these cases, the drug is covered for its primary therapeutic use, even if the patient experiences weight loss as a significant side effect.

Furthermore, the policy landscape is shifting rapidly. Following a new administration pilot program announced in late 2025, coverage for Anti-Obesity Medications (AOMs) is now expected to significantly expand, beginning as early as mid-2026. This pilot program will specifically target beneficiaries with obesity and related comorbidities, signaling a major policy shift toward recognizing obesity as a chronic disease requiring pharmacological treatment.

Why Trust This Information: Navigating the Complexities of CMS Rules

Navigating Medicare rules requires a high degree of precision, especially when interpreting statutory exclusions and shifting regulatory proposals. The content herein is built upon a direct analysis of the legal language of the Social Security Act and the formal guidance issued by the Centers for Medicare & Medicaid Services (CMS). By relying on these authoritative sources—including final and proposed rules for upcoming contract years—we ensure that the information reflects the official coverage guidelines and their nuanced, indication-based applications. This foundational approach is essential for providing beneficiaries with the accurate, actionable guidance they need to secure coverage.

The Critical ‘Indication’ Rule: Key to Getting Anti-Obesity Drug Coverage

The distinction between a drug prescribed for weight loss and one prescribed to treat an underlying disease is the single most important factor determining Medicare Part D coverage for medications like GLP-1 agonists. This distinction is not arbitrary; it is rooted in a fundamental piece of legislation.

How ‘Medically Accepted Indication’ Opens the Door for Part D Coverage

The core legal hurdle preventing automatic coverage for weight loss drugs stems from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This federal statute contains an explicit exclusion, codified in the Social Security Act, which bans Medicare Part D plans from covering agents used only for anorexia, weight loss, or weight gain.

Because of this statutory language, Medicare Part D plans may only cover a medication if it is prescribed for an FDA-approved “medically accepted indication” that is not one of the specifically excluded uses. This is why a drug’s primary approval matters less than its full list of approved indications. An anti-obesity medication transforms into a covered drug the moment the Food and Drug Administration (FDA) grants it a second, non-weight-loss-related approval.

Understanding the Difference: Weight Loss vs. Disease Treatment

To illustrate this critical difference, consider the drug Wegovy (semaglutide). While it was initially approved for chronic weight management in individuals with obesity or overweight and a related comorbidity, Medicare did not cover it under that indication.

However, following a major clinical trial, the FDA granted Wegovy a new, separate indication: to reduce the risk of cardiovascular death, non-fatal heart attack, and non-fatal stroke in adults with established cardiovascular disease and either obesity or overweight. This approval provided a medically accepted indication that is not purely for weight loss, immediately opening a pathway for Medicare Part D coverage for millions of eligible beneficiaries. The ability to cite the specific language of the Social Security Act regarding statutory exclusions, alongside the Centers for Medicare & Medicaid Services (CMS) guidance on a drug’s additional indications, provides expert-level accuracy that empowers beneficiaries to fight for the coverage they are due. By linking the drug to the treatment of a chronic, life-threatening condition (cardiovascular disease), the prescription shifts from a statutory exclusion to a covered benefit.

Specific Drug Analysis: Ozempic, Wegovy, Zepbound, and Mounjaro on Medicare

Semaglutide (Ozempic/Wegovy): The Dual-Indication Landscape

Semaglutide, the active ingredient in both Ozempic and Wegovy, perfectly illustrates the complexity of Medicare Part D coverage. The key to securing a covered prescription lies in the specific medical reason for its use. For a beneficiary to receive coverage for the medication, the Centers for Medicare & Medicaid Services (CMS) rules are explicit: the drug must be prescribed for an FDA-approved medically accepted indication that is not purely for weight management.

In practice, this means that Ozempic, which is specifically FDA-approved to treat Type 2 diabetes, is typically covered when prescribed for that condition. Even though patients commonly experience significant weight reduction as a powerful side effect, the official, covered use is for glycemic control. Conversely, Wegovy, which is a higher dose of semaglutide primarily approved for chronic weight management, was historically excluded from Part D. However, the FDA’s 2024 approval of Wegovy for the reduction of major adverse cardiovascular events (like heart attack or stroke) in adults with established cardiovascular disease and obesity or overweight has created a specific, new Part D coverage pathway for millions of beneficiaries. This change demonstrates a critical shift in how federal policy recognizes the benefits of these drugs beyond blood sugar control.

Tirzepatide (Mounjaro/Zepbound): Navigating Coverage for New Medications

Tirzepatide, a dual-acting glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist, follows a similar dual-brand, dual-indication model. Mounjaro is the brand name approved by the FDA for the treatment of Type 2 diabetes. Therefore, coverage under Medicare Part D is contingent upon this official diabetes diagnosis and is subject to the plan’s formulary rules, such as prior authorization.

Zepbound is the brand name approved for chronic weight management. Similar to Wegovy’s previous status, Zepbound for weight loss alone is excluded from mandatory Part D coverage under current statutory language. While Part D plans may soon be able to cover Zepbound for other indications, such as obstructive sleep apnea in adults with obesity (an indication the drug has been approved for), this coverage remains indication-specific and must be clearly documented by the prescribing physician to meet the plan’s requirements.

Which Drug Is Covered for Which Condition?

To help beneficiaries and providers navigate the often-confusing formulary rules, the table below summarizes the current status of the most common GLP-1 and GIP/GLP-1 receptor agonists under Medicare Part D. This information is based on the statutory exclusions and the official FDA-approved non-weight-loss indications that open the door to coverage.

Drug Name (Active Ingredient)	Primary Brand Name(s)	FDA-Approved Non-Weight-Loss Indication	Medicare Part D Coverage Status
Semaglutide	Ozempic (Injection)	Type 2 Diabetes; Cardiovascular Risk Reduction	Covered for these non-weight-loss indications (subject to formulary)
Semaglutide	Wegovy (Injection)	Reduction of Major Adverse Cardiovascular Events (MACE) in adults with established CVD	Covered for this specific cardiovascular risk reduction indication
Tirzepatide	Mounjaro (Injection)	Type 2 Diabetes	Covered for Type 2 Diabetes (subject to formulary)
Tirzepatide	Zepbound (Injection)	Obstructive Sleep Apnea in adults with obesity	Potentially Covered for this non-weight-loss indication (varies by plan)

Note: All coverage is contingent upon the specific Medicare Part D plan’s formulary and successfully meeting any Prior Authorization or Step Therapy requirements set by the plan.

Cost and Accessibility: What to Expect with New Policy Changes in 2026

The high cost of GLP-1 drugs for covered indications is a significant barrier for many beneficiaries, but ongoing policy negotiations and legislative efforts are poised to dramatically reshape the financial landscape. As the healthcare system recognizes the long-term value of treating chronic conditions aggressively, cost-saving measures and expanded coverage are on the horizon, largely impacting Part D enrollees starting in 2026.

Projected Cost Savings: New Copayments and Pricing Agreements

For Medicare beneficiaries who can secure coverage for GLP-1 medications—such as Ozempic for Type 2 diabetes or Wegovy for established cardiovascular disease—a major shift is underway. Following recent administration efforts and pricing negotiations, out-of-pocket costs are expected to fall for covered medications. Specifically, copayments for certain covered GLP-1 drugs are expected to be around $50 per month after deductibles are met, representing a significant reduction in monthly expenses compared to the drugs’ standard retail price.

This move is part of a larger government strategy to leverage its purchasing power. While the immediate focus is on covered, non-weight-loss indications, experts are analyzing the long-term impact of broader coverage. The Congressional Budget Office (CBO) has analyzed the fiscal impact of eliminating the statutory weight-loss exclusion entirely, projecting it would increase federal spending on Medicare by an estimated $35 billion from 2026 to 2034. However, the CBO also noted that health care savings from reduced obesity-related health problems, while small initially, would grow substantially in the second decade (2035-2044) as chronic disease rates fall, demonstrating a strong public health justification for these high-value treatments.

When Will Expanded Coverage for Obesity Treatment Begin?

The most anticipated change—the potential for Medicare Part D to cover medications specifically for the treatment of obesity—is tentatively scheduled for implementation starting mid-2026.

This timeline is based on proposed rule changes that would permit coverage for anti-obesity medications (AOMs) for beneficiaries with obesity and related comorbidities. While Medicare is statutorily prohibited from covering drugs solely for weight loss, the Centers for Medicare & Medicaid Services (CMS) have proposed administrative interpretations and pilot programs, such as the GENEROUS model announced in late 2025, that target the treatment of obesity as a chronic, medically accepted condition. As the policy evolves, beneficiaries should expect new options to become available, likely phased in throughout 2026, targeting individuals with high BMI and cardiovascular risk factors.

Potential Limits: Prior Authorization and Utilization Management Tools

While cost savings and expanded eligibility are great news, beneficiaries must prepare for significant utilization management tools employed by Part D plans. Even with coverage, access is rarely automatic.

Prior Authorization (PA): Plans will almost universally require Prior Authorization. This means the prescribing physician must submit extensive documentation proving the drug is being used for a Part D-covered indication (like Type 2 diabetes or cardiovascular risk reduction) or that the patient meets the clinical criteria for the new, expanded obesity treatment programs. This documentation must clearly establish medical necessity.
Step Therapy: Many plans will also use Step Therapy protocols, requiring the patient to first try a less-expensive, often older medication to treat the condition before the GLP-1 drug will be covered.
BMI Requirements: For any potential coverage through the expanded 2026 guidelines, specific Body Mass Index (BMI) and comorbidity requirements will be enforced by the plan’s formulary.

The KFF (Kaiser Family Foundation), which tracks health policy, has noted that even as GLP-1 drugs are being covered for authorized uses, Part D gross spending on these drugs has skyrocketed, underscoring the pressure on plan budgets. Consequently, these utilization management tools (PA and step therapy) are essential for plans to manage the financial risk and ensure appropriate use of these high-cost medications, which is a key factor in keeping Part D premiums stable for all enrollees.

Alternative Weight Management Services Covered by Medicare

While coverage for GLP-1 and other anti-obesity medications can be highly complex and restrictive under Medicare Part D, the program does offer significant coverage for non-pharmacological weight management services. These services, which focus on lifestyle modification and, when necessary, surgical intervention, are essential components of comprehensive obesity care and can be covered under different parts of Original Medicare.

Medicare Part B Coverage for Obesity Screening and Counseling

Medicare Part B covers Intensive Behavioral Therapy (IBT) for Obesity, an important, no-cost service for eligible beneficiaries. This coverage is specifically designed to support long-term behavioral change. To qualify, a patient must have a Body Mass Index (BMI) of 30 or greater. The service is covered when delivered by a primary care physician (PCP) or other qualified primary care practitioner in a primary care setting, and it is provided at no cost to the patient—the Part B deductible and copayments are waived.

The counseling, which is billed using HCPCS code G0447, follows a specific schedule: one face-to-face visit every week for the first month, one every other week for months two through six, and then monthly visits for months seven through twelve if the beneficiary has achieved a weight loss of at least 6.6 pounds (3 kg) during the first six months. This structured approach, backed by Centers for Medicare & Medicaid Services (CMS) guidelines, ensures patients receive the high-intensity support needed to initiate and sustain meaningful change.

Bariatric Surgery: When Medicare Part A and B Will Pay

For individuals with severe or morbid obesity, Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) may cover bariatric surgical procedures, such as Roux-en-Y gastric bypass and sleeve gastrectomy. Coverage for these procedures is contingent upon meeting stringent medical necessity criteria:

The patient must have a Body Mass Index (BMI) of 35 or higher.
The patient must have at least one obesity-related comorbidity (co-occurring condition), such as Type 2 diabetes, cardiovascular disease, hypertension, or severe obstructive sleep apnea.
The patient must have been previously unsuccessful with medical treatments for obesity.

Part A typically covers the inpatient hospital stay if the procedure requires an overnight admission, while Part B covers the services provided by the surgeons and other outpatient services. This coverage demonstrates Medicare’s recognition of obesity as a serious medical condition when it leads to severe health complications.

Medical Nutrition Therapy: Eligibility Requirements

While not strictly for weight loss, Medicare Part B covers Medical Nutrition Therapy (MNT), which involves a comprehensive nutritional assessment and counseling services delivered by a Registered Dietitian Nutritionist (RDN). Crucially, MNT is only covered for beneficiaries with diabetes or kidney disease. For individuals who meet these clinical criteria, MNT is an integral service that can assist in managing these conditions, which often co-exist with obesity. For patients receiving GLP-1 medications for diabetes, MNT can provide the dietary guidance necessary to maximize the therapeutic benefits. As Dr. Lydia Alexander, Immediate Past President of the Obesity Medicine Association (OMA), notes, “GLP-1 therapies are powerful, but they’re most effective when paired with intentional, nutrient-dense eating patterns that support metabolic health and long-term success. Nutrition is not an afterthought—it’s a therapeutic partner.” This expert consensus underscores the importance of utilizing all available Medicare-covered resources, including counseling and MNT, to complement any medication-based treatment for optimal, sustained health outcomes.

Actionable Steps: How to Request and Fight for Medicare Drug Coverage

Securing coverage for GLP-1 medications under Medicare is often a multi-step process that requires strategic action and clear documentation. Given the statutory exclusions against covering medications solely for weight management, success relies on demonstrating the drug’s use for a separate, medically necessary, FDA-approved condition like Type 2 diabetes or cardiovascular risk reduction.

The Role of Your Doctor: Documentation for ‘Medical Necessity’

The first and most critical action you must take is to collaborate closely with your prescribing physician. The initial step for patients is securing a Letter of Medical Necessity (LOMN) from their doctor. This letter is the central piece of evidence, clearly stating the FDA-approved, non-weight-loss indication for which the GLP-1 drug is being prescribed.

This LOMN should explicitly detail your diagnosis (e.g., Type 2 diabetes, established cardiovascular disease, etc.), explain why the requested medication (e.g., Ozempic, Wegovy) is superior to or necessary over alternatives on the plan’s formulary, and reference clinical guidelines or data that support the use of the drug for the covered condition. A well-written LOMN transforms the request from one for a “weight loss drug” into one for a treatment for a covered, chronic disease, significantly increasing the probability of a successful coverage determination.

Understanding Your Plan’s Formulary (Drug List)

Before you or your doctor submit a prescription, you must familiarize yourself with your specific Medicare Part D plan’s formulary (its list of covered drugs). Formularies are subject to change annually and vary widely between plans.

Check for three common formulary restrictions:

Prior Authorization (PA): You must get approval from the plan before the drug is covered.
Step Therapy (ST): You may be required to try a less expensive, comparable drug first (e.g., generic metformin) before the plan will cover the requested GLP-1.
Quantity Limits (QL): The plan may limit the amount of the drug you can receive per fill.

If your desired medication is not on your formulary or is subject to one of these restrictions, your doctor will need to file an Exception Request as part of the initial coverage determination process. Your Letter of Medical Necessity serves as the clinical justification for this exception.

The Appeals Process: What to Do if Your Claim is Denied

If your initial request for a coverage determination (or exception request) is denied, you have the right to an official five-level appeals process, a right established under the Centers for Medicare & Medicaid Services (CMS) regulations. This process is structured to provide independent reviews and ensures a pathway for recourse.

If your coverage is denied, Part D enrollees have the right to an official five-step appeals process, beginning with a request for Redetermination from the plan itself.

Here is a step-by-step checklist for navigating the formal Medicare Part D appeals stages:

Level	Reviewing Entity	Action Required	Standard Timeframe for Decision
Level 1	The Part D Plan (Redetermination)	Request a Redetermination (first formal appeal) in writing within 60 days of the denial notice. Include your LOMN and any new supporting evidence.	7 days
Level 2	Independent Review Entity (IRE)	Request a Reconsideration by the IRE (a neutral entity not affiliated with your plan) within 60 days of the Level 1 denial.	7 days
Level 3	Administrative Law Judge (ALJ)	Request a hearing with an ALJ if the amount of the claim meets a minimum dollar threshold (e.g., $$190$ in 2025).	90 days
Level 4	Medicare Appeals Council	Request a review of the ALJ’s decision.	90 days
Level 5	Federal District Court	Request judicial review if the amount in controversy meets a higher threshold (e.g., $$1,900$ in 2025).	Varies

For urgent cases, you or your doctor can request an Expedited (Fast) Appeal at Levels 1 and 2, which requires a decision within 72 hours. Carefully adhering to these formal deadlines and requirements is essential to maximizing your chances of a successful reversal.

Your Top Questions About Medicare and Anti-Obesity Drug Coverage Answered

Q1. Will Medicare cover a weight loss drug if I also have high blood pressure?

The key to Medicare Part D coverage for GLP-1 medications like Ozempic, Wegovy, Mounjaro, or Zepbound is its medically accepted indication, not simply the presence of a comorbidity like high blood pressure (uncontrolled hypertension).

While high blood pressure is a common comorbidity, current Medicare law requires the drug to be prescribed for an FDA-approved purpose that is not solely weight loss. This means:

Ozempic, Mounjaro, and others are covered when prescribed for their primary, FDA-approved use: Type 2 Diabetes management.
Wegovy (and potentially others in the future) is covered when prescribed for its secondary, FDA-approved use: reducing the risk of cardiovascular death, heart attack, and stroke in adults with established cardiovascular disease and obesity or overweight.

Therefore, simply having high blood pressure is not enough to guarantee coverage. However, if that comorbidity—or the combination of obesity and that comorbidity—is explicitly tied to an FDA-approved indication for the drug (such as the established cardiovascular disease indication for Wegovy), then coverage becomes possible, provided your specific Part D plan includes the drug on its formulary. The government’s recent agreements with drug manufacturers, expected to expand coverage in mid-2026, explicitly include conditions like uncontrolled high blood pressure for beneficiaries with a BMI greater than 30 as a new pathway to coverage. This is a significant policy shift.

Q2. Is there a BMI requirement for Medicare-covered obesity counseling?

Yes, there is a specific Body Mass Index (BMI) requirement.

Medicare Part B provides coverage for Intensive Behavioral Therapy (IBT) for obesity. To be eligible for this counseling, you must have a Body Mass Index (BMI) of 30 or greater.

This benefit, which requires the counseling to be provided by a primary care doctor or other primary care practitioner in a primary care setting, is considered a preventive service. It includes:

An initial screening for obesity.
A dietary assessment.
Intensive behavioral counseling sessions focused on diet and exercise.

The service is typically covered for up to 22 visits over 12 months, with no Part B deductible or copay, as long as the provider accepts Medicare assignment. This is an example of Medicare providing support for comprehensive obesity treatment as part of its commitment to establishing trust and credibility in the medical necessity of these services.

Q3. How does Medicare Advantage coverage for these drugs differ from Original Medicare?

In the context of mandatory prescription drug coverage, Medicare Advantage (Part C) plans that include drug coverage (MA-PD plans) must adhere to the same legal rules as a standalone Original Medicare Part D plan.

Mandatory Coverage: Both Original Medicare Part D and Medicare Advantage Part D must legally exclude drugs prescribed solely for weight loss. They must cover GLP-1 drugs when prescribed for an FDA-approved, non-excluded indication (like Type 2 Diabetes or cardiovascular risk reduction).
Formulary Variation: Coverage still depends on the specific MA-PD plan’s formulary. One plan may cover a specific GLP-1 drug on a different tier or with different prior authorization rules than another.
Enhanced Benefits: The key difference is that Medicare Advantage plans may offer additional, non-mandatory benefits for weight management that Original Medicare does not. These can include:
- Fitness program memberships (e.g., SilverSneakers).
- Wellness benefits or allowances that can be used for health-related services.
- Expanded coverage for non-drug weight loss programs.

Therefore, while the core drug coverage rules are the same, a Medicare Advantage plan might provide more comprehensive overall support for health and weight management than Original Medicare.

Final Takeaways: Mastering Medicare Weight Loss Drug Coverage in 2026

Summary of 3 Key Actionable Steps for Beneficiaries

Navigating the rules for Part D coverage of GLP-1 and similar medications can be challenging, but a clear, strategic approach is essential to securing access. The single most important takeaway—which reflects the statutory language of the Social Security Act—is that Medicare Part D does not cover weight loss drugs for weight loss. Coverage is only triggered when the drug is prescribed for an alternative, co-occurring, FDA-approved condition, such as Type 2 diabetes or established cardiovascular disease.

To maximize your chances of coverage, focus on these three actionable steps:

Secure Indication-Specific Documentation: Work with your prescribing physician to ensure your medical records and the Letter of Medical Necessity clearly state the FDA-approved non-weight-loss indication, such as Type 2 diabetes or cardiovascular risk reduction (in the case of Wegovy). This documentation must directly tie your need to a covered use to satisfy the insurer’s requirements for utilization management.
Scrutinize Your Plan’s Formulary: Always check your specific Part D plan’s Drug List (formulary) during the Annual Enrollment Period. Even for covered indications, plans can apply cost-control measures like prior authorization (PA) and step therapy. Be prepared for these potential requirements.
Be Ready to Appeal a Denial: If your claim is denied, Part D beneficiaries have the right to a five-step appeals process. Start immediately by requesting a formal redetermination from your Part D plan. Consulting the official Centers for Medicare & Medicaid Services (CMS) guidelines for prescription drug appeals will provide the most authoritative guidance for this bureaucratic process.

What to Do Next: Staying Informed on Policy Updates

The landscape of medication coverage for conditions like obesity is rapidly changing, driven by new drug approvals and policy debates. For example, while past administrations have introduced proposed rules to reinterpret the statutory exclusion, the latest final rules for the 2026 benefit year have, at times, left the exclusion in place, making coverage hinge on the co-occurring condition.

To remain ahead of these shifts and monitor the potential mid-2026 coverage expansions related to administrative deals, beneficiaries should make it a habit to review the latest CMS proposed and final rules for 2026/2027. This level of detail, though complex, is the best source of expert-level information on timelines for expanded access and projected policy changes.