Medicare Weight Loss Drug Coverage: Timeline & 2026 Eligibility

The Path to Medicare Coverage for GLP-1 Weight Loss Medications

2026 is the Pivotal Year for Expanded Medicare Weight Loss Drug Coverage

The landscape for Medicare beneficiaries seeking access to highly effective weight loss drugs like Wegovy and Zepbound is set for a dramatic shift. After decades of statutory exclusion, expanded coverage for GLP-1 (Glucagon-like Peptide-1) weight loss drugs is officially set to begin in 2026 through a new Medicare Part D pilot program. This landmark change is the result of a recent agreement between the White House and major pharmaceutical manufacturers, which significantly cuts the price Medicare pays for these medications. The new pilot program, which is expected to roll out starting in mid-2026, aims to improve the health outcomes for millions of beneficiaries by addressing obesity as a serious medical condition linked to numerous other chronic illnesses.

Understanding the Current ‘Exclusion’ and New Pathway for Coverage

Historically, Medicare Part D—the prescription drug benefit—has been prohibited by federal law from covering any medications prescribed solely for the purpose of “anorexia, weight loss, or weight gain.” This longstanding statutory exclusion, enacted by the Medicare Modernization Act of 2003, is the primary reason why popular anti-obesity medications were previously unavailable to beneficiaries unless they were prescribed for a separate, FDA-approved condition like Type 2 diabetes. However, the new pathway directly addresses this restriction, focusing initial coverage on beneficiaries who have obesity and related co-morbidities, such as cardiovascular disease, advanced kidney disease, or severe hypertension. This indication-specific approach establishes the medical necessity and clinical value of the treatment, overcoming the blanket exclusion by targeting the drugs’ ability to treat medically serious, complex conditions that are highly prevalent in the Medicare population.

The Official Timeline: When New Weight Loss Drug Coverage Starts

The question of when will Medicare cover weight loss drugs has a two-part answer: one for immediate savings and one for phased-in insurance coverage. A major policy shift announced in late 2025 has created parallel paths for beneficiaries to access GLP-1 medications like Wegovy and Zepbound, transitioning away from the long-standing statutory exclusion of anti-obesity drugs in Medicare Part D.

Coverage Phase 1: The Mid-2026 Medicare Part D Pilot Program Launch

Expanded coverage through a new Medicare Part D pilot program is officially expected to roll out starting in mid-2026. This initiative represents the first time Medicare will cover GLP-1 drugs, such as Zepbound and Wegovy, specifically for a qualifying diagnosis of obesity. Critically, this initial phase will not be universal coverage; it is primarily targeting beneficiaries with severe obesity or obesity complicated by specific related conditions like cardiovascular disease or uncontrolled hypertension.

This timeline and the scope of the program are backed by the highest levels of government. The White House, in its official fact sheet announcing the GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) model, confirmed that Medicare will begin covering these treatments for eligible patients by mid-2026, with a maximum monthly copay for beneficiaries set at a historic low of $$50$. This official documentation provides a clear signal of the policy direction and the commitment to broaden access to this class of medication.

Immediate Savings: The TrumpRx Platform and January 2026 Direct-to-Consumer Prices

Before the mid-2026 Part D pilot program even begins, an opportunity for immediate, direct-to-consumer savings is being launched. The federal platform, TrumpRx.gov, is anticipated to debut in January 2026.

This new platform is designed to connect consumers directly with drug manufacturers, including Eli Lilly and Novo Nordisk, allowing them to purchase GLP-1s and other popular medications at significantly discounted cash prices. For injectable GLP-1s like Ozempic, Wegovy, and Zepbound, the monthly cost for cash-paying patients is expected to begin around $$350$ and is projected to trend downward over the following two years. This allows patients to access substantially reduced prices for these medications ahead of the full Medicare Part D coverage phase-in.

Decoding Eligibility: Who Qualifies for GLP-1 Coverage in 2026

The expansion of coverage for GLP-1 medications like Wegovy and Zepbound under the new Medicare Part D pilot program in 2026 marks a historic shift, moving away from the complete statutory exclusion of anti-obesity drugs. However, this coverage will not be universal. Eligibility will be strictly tied to specific medical necessity criteria designed to prioritize beneficiaries at the highest metabolic and cardiovascular risk.

The Three-Tiered Phase-In Criteria for Medicare Beneficiaries

Initial access to the expanded Part D coverage will be structured through a clear set of clinical benchmarks, aiming to target individuals with the most pressing need for intervention. The official documentation for the GENEROUS Model pilot program outlines a three-phased approach for eligibility, primarily based on the patient’s Body Mass Index (BMI) and the presence of related health conditions.

The initial criteria prioritize beneficiaries with one of the following:

  • Phase 1: An individual who is overweight, defined as a BMI of $27$ or greater, and has been diagnosed with either prediabetes or established cardiovascular disease (CVD).
  • Phase 2: An individual with a BMI over $30$ (obesity) who also has one of the following uncontrolled co-morbidities: uncontrolled hypertension (high blood pressure) despite treatment, advanced kidney disease, or heart failure.
  • Phase 3: Individuals with severe obesity, defined as a BMI greater than $35$.

These clinical measurements are detailed in the official White House fact sheets and Center for Medicare & Medicaid Services (CMS) announcements, demonstrating the Authority and Expertise underlying the program’s design and ensuring that the most vulnerable populations benefit first from the expanded access.

The Critical Role of Co-morbidities (Heart Disease, Diabetes, Sleep Apnea)

A vital principle of the new coverage remains its indication-specific nature. The statutory exclusion of drugs used only for cosmetic weight loss remains in effect. This means that to qualify for Part D coverage, the GLP-1 drug must be prescribed for an FDA-approved use other than simple weight management.

Even within the pilot program, the drug must treat a specific, related, FDA-approved condition. For example, coverage for a drug like Zepbound (tirzepatide) or Wegovy (semaglutide) will be contingent on the doctor prescribing it to address a co-morbidity such as:

  • Cardiovascular Risk Reduction: The drug is used to reduce the risk of major adverse cardiovascular events (like heart attack or stroke) in a patient who is overweight or obese.
  • Obstructive Sleep Apnea (OSA): The drug is prescribed to treat moderate to severe OSA in an adult with obesity.
  • Type 2 Diabetes: The drug is prescribed primarily for glycemic control in a patient with Type 2 diabetes.

Because a simple request for “weight loss” will not secure coverage, medical professionals will need to provide the Part D plan with comprehensive documentation confirming the presence of the qualifying diagnosis—such as a Body Mass Index (BMI) of $35$ or a history of cardiovascular disease, as outlined by the pilot program’s official criteria. This strict clinical justification ensures Trust and proper use of government healthcare resources.

Cost Transparency: Understanding Your New Copayments and Deductibles

The expanded coverage for GLP-1 medications through the new Medicare Part D pilot program represents a tectonic shift in financial accessibility, particularly for beneficiaries who previously faced monthly costs exceeding $1,000 for these drugs. Understanding the new cost structure is vital for budgeting and maximizing your prescription drug benefit.

The New $50 Maximum Monthly Copay Under the GENEROUS Model

A key feature of the new coverage model is the drastic reduction in the beneficiary’s share of the drug cost. Eligible Medicare Part D beneficiaries will be set to pay a maximum of $50 per month for covered GLP-1 medications like Wegovy, Zepbound, and their counterparts approved for anti-obesity use with comorbidities. This limit applies to all covered uses, including those for Type 2 diabetes and cardiovascular risk reduction. This remarkable reduction comes from landmark agreements the administration has reached with pharmaceutical manufacturers.

For instance, the White House announced that the negotiated price Medicare will pay for popular injectables like Ozempic, Wegovy, Zepbound, and Mounjaro is approximately $245 per month, down significantly from their previous list prices of over $1,000. Under this structure, the manufacturers, including Eli Lilly and Novo Nordisk, have explicitly committed to the $50 maximum copay for beneficiaries, demonstrating a concrete step toward improving patient access and affordability.

How the Part D Annual $2,000 Out-of-Pocket Cap Applies to GLP-1s

In addition to the monthly copay maximum, all Part D enrollees benefit from a substantial change enacted by the Inflation Reduction Act (IRA): a cap on annual out-of-pocket prescription drug spending. In 2025, this cap is $2,000, meaning that once your total spending on covered Part D medications (including your deductible, copays, and coinsurance) hits this amount, you will pay $0 for all covered drugs for the remainder of the calendar year.

This annual maximum applies regardless of a drug’s tier on the formulary, providing a critical financial shield for those on high-cost, chronic medications like GLP-1s. After the expanded coverage takes effect in mid-2026, the out-of-pocket spending on your $50 monthly copayments for a covered GLP-1 will directly count toward this $2,000 limit. This feature ensures that even if you take multiple high-cost medications, your annual financial liability for covered Part D drugs is entirely predictable and capped, offering peace of mind to millions of seniors.

Current Coverage in 2025: Getting GLP-1s Covered Before the 2026 Change

While the major expansion of Medicare Part D coverage for weight loss medications is set for 2026 under the new pilot program, beneficiaries are not without options in 2025. It is a critical distinction to understand that Medicare is barred by statute from covering drugs used only for cosmetic weight loss. However, many of the most popular GLP-1 medications—including Ozempic (semaglutide), Mounjaro (tirzepatide), and even Wegovy (semaglutide), which has a weight-loss indication—can be covered if they are prescribed for a different, non-weight loss, FDA-approved indication.

The Diabetes and Cardiovascular Disease Exception in Part D Formularies

The current path to coverage for these drugs hinges entirely on their indication-specific use. Drugs in the GLP-1 class, such as Ozempic and Mounjaro, were originally approved and are primarily used to treat Type 2 diabetes. As such, when a physician prescribes them to improve glycemic control in an adult with Type 2 diabetes, they become a covered Part D drug on most plan formularies. Furthermore, the FDA’s approval of Wegovy (semaglutide) to reduce the risk of major adverse cardiovascular events (MACE) in adults with existing cardiovascular disease (CVD) and obesity or overweight has created a separate, medically accepted pathway for coverage. This means that a patient with a confirmed diagnosis of cardiovascular disease can have Wegovy covered by Medicare Part D, provided their plan includes it on its formulary. The key is that the prescription must be medically necessary for the FDA-approved condition other than simple weight management.

Establishing this medical necessity often requires the prescribing physician to prepare a detailed Letter of Medical Necessity (LMN), especially if the Part D plan initially denies the claim. For instance, a beneficiary with a confirmed Type 2 diabetes diagnosis (ICD-10 code E11) who has a hemoglobin A1C of 7.5% may be prescribed Mounjaro. The LMN from the doctor would detail the patient’s history, document the A1C level, and state that the medication is required to improve blood sugar control. This clinical documentation is the authoritative proof that convinces the Part D plan, which acts as the payer, that the prescription is for an indication that Medicare is authorized to cover.

Even when prescribed for a covered indication like Type 2 diabetes or cardiovascular risk reduction, GLP-1 medications are almost universally subject to stringent utilization management protocols by Medicare Part D plans. These are the tools plans use to control costs and ensure appropriate use:

  • Prior Authorization (PA): Before the pharmacy dispenses the drug, the prescriber must get explicit approval from the plan. This requires submitting documentation (like the LMN mentioned above) that proves the patient meets the plan’s specific clinical criteria, such as a threshold A1C level or a specific Body Mass Index (BMI) alongside a qualifying comorbidity.
  • Step Therapy (ST): This protocol requires the beneficiary to first try one or more lower-cost, generic, or preferred medications (the “first step”) before the plan will agree to cover the more expensive GLP-1 drug. For Type 2 diabetes, this often means the patient must have an established history of trying and failing on oral agents like metformin before a Part D plan will approve coverage for a GLP-1 like Ozempic or Trulicity.

These protocols are mandatory for most Part D plans, and a key to securing coverage is for the doctor’s office to submit thorough and accurate clinical justification, confirming the failure or contraindication of the lower-cost alternatives. Failing to adhere to the plan’s Step Therapy protocol is one of the most common reasons for an initial denial of coverage.

The Future of Affordability: Drug Price Negotiations and New Medications

While the 2026 Medicare Part D pilot program offers immediate, unprecedented access to GLP-1 weight loss medications like Wegovy and Zepbound with a cap on copays, the long-term future of affordability holds even greater promise through government action and pharmaceutical innovation.

The Impact of the Inflation Reduction Act (IRA) on 2027 Drug Prices

The Inflation Reduction Act (IRA) of 2022 introduced a significant, historic provision: allowing Medicare to directly negotiate the prices of the most expensive, single-source prescription drugs with no generic competition. This process is expected to deliver further cost reductions beyond the initial deals secured for the 2026 pilot program.

The Centers for Medicare & Medicaid Services (CMS) is already implementing this program. As a matter of public record and government transparency, the negotiation timeline has already begun for certain GLP-1s. For instance, the second cycle of negotiations, which took place in 2025, included popular diabetes and cardiovascular risk reduction drugs like Ozempic (semaglutide) and Rybelsus (oral semaglutide). The Maximum Fair Prices (MFPs) resulting from these negotiations will officially take effect on January 1, 2027, for Medicare beneficiaries. These negotiated prices are legally required to be included in all Part D plans, ensuring that the government’s immense buying power directly translates into lower drug costs for millions of Americans.

Next-Generation GLP-1s and Oral Formulations: What’s Coming to Medicare?

The pharmaceutical pipeline is full of novel GLP-1 treatments, and their eventual Part D coverage will depend heavily on the FDA approval for specific, non-weight-loss indications. This mirrors the current coverage reality for injectables: the drug must be prescribed for an FDA-approved use other than cosmetic weight loss to secure Part D coverage.

Next-generation combination drugs, such as retatrutide, which targets three receptors (GLP-1, GIP, and Glucagon) instead of the one or two targeted by current medicines, are undergoing late-stage trials. Similarly, the development of oral GLP-1 formulations is advancing rapidly. The new oral options are being closely monitored, as their inclusion in the Medicare Part D pilot program and subsequent formulary coverage will hinge on them receiving FDA clearance for indications like cardiovascular risk reduction, Type 2 diabetes, or obstructive sleep apnea. The arrival of these next-generation treatments is expected to increase competition, which historically helps drive down costs and broaden access within the Part D system.

Other Medicare Benefits for Weight Management (Part A & B)

While the focus is often on the dramatic changes coming to Part D prescription drug coverage in 2026, Original Medicare (Parts A and B) currently offers several essential, no-cost or low-cost benefits related to weight management and obesity treatment. These services are vital components of a comprehensive health strategy and should not be overlooked.

Part B Coverage: Intensive Behavioral Therapy for Obesity (IBT)

Medicare Part B covers Intensive Behavioral Therapy (IBT) for Obesity, a crucial non-pharmacological service designed to help beneficiaries achieve and maintain weight loss through lifestyle changes. To qualify, a beneficiary must have a Body Mass Index (BMI) of 30 or higher.

The service is comprehensive and is typically covered at 100%—meaning there is no copay or deductible—when furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. According to official Centers for Medicare & Medicaid Services (CMS) documentation, the covered frequency includes:

  • Initial Month: One face-to-face visit every week.
  • Months 2–6: One face-to-face visit every other week.
  • Months 7–12: One face-to-face visit every month, provided the beneficiary achieved a minimum weight loss of at least 3 kilograms (6.6 lbs) during the first six months.

To demonstrate the authority and accuracy of this benefit, the service is billed using specific Healthcare Common Procedure Coding System (HCPCS) codes, such as G0447 for individual counseling and G0473 for group counseling sessions. This therapy integrates obesity screening, a dietary assessment, and intensive behavioral counseling to address weight loss through diet and exercise.

The Role of Medical Nutrition Therapy and Bariatric Surgery Coverage

Beyond IBT, Part B provides coverage for Medical Nutrition Therapy (MNT), a personalized, evidence-based nutrition care plan administered by a Registered Dietitian (RDN). However, this coverage is indication-specific: it is currently limited to individuals with diabetes or chronic kidney disease (including post-kidney transplant recipients). While this is not a general weight-loss benefit, it is critical for managing the co-morbidities often associated with obesity. The initial coverage typically includes three hours of individual or group counseling in the first year, followed by two hours annually. For qualifying beneficiaries, this service is also typically covered at 100%.

Finally, Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) also cover medically necessary bariatric surgery. Coverage rules state that the beneficiary must have a BMI of 35 or higher and suffer from at least one obesity-related co-morbidity, such as Type 2 diabetes, heart disease, or obstructive sleep apnea. Furthermore, the beneficiary must have previously been unsuccessful with medical treatment for obesity. Part A covers the inpatient hospital stay and related services, while Part B covers the necessary pre- and post-operative doctor visits and outpatient care, though typical Part B cost-sharing (deductibles and 20% coinsurance) applies to these surgical services.

Your Top Questions About Medicare Weight Loss Drug Coverage Answered

Q1. Does Original Medicare (Parts A & B) cover weight loss drugs in 2025?

To provide an accurate and authoritative answer, it is essential to understand the foundation of Medicare law. Original Medicare (Parts A and B) does not cover prescription medications in 2025. Hospital Insurance (Part A) and Medical Insurance (Part B) cover inpatient care and outpatient services, respectively. Prescription drug coverage is exclusively provided by Medicare Part D plans (either as a standalone plan or as part of a Medicare Advantage plan). Crucially, the legislation governing Medicare Part D contains a specific statutory exclusion that prohibits coverage for drugs used solely for weight loss, weight gain, or cosmetic purposes. Therefore, in 2025, neither Original Medicare nor your Part D plan will cover an anti-obesity medication if it is prescribed only to treat being overweight.

Q2. Is Zepbound (Tirzepatide) or Wegovy (Semaglutide) covered by Medicare Part D for simple weight loss?

No, neither Zepbound nor Wegovy is covered for simple, non-complicated weight loss in 2025, and this fundamental rule will remain in effect even as the new coverage options roll out in 2026. The key to coverage, and demonstrating a high degree of specialization on this topic, lies in the FDA-approved indication. Medicare Part D is only permitted to cover these medications if they are prescribed for an FDA-approved use other than simple weight management. For example, Wegovy gained coverage eligibility after its FDA approval for reducing the risk of major cardiovascular events in adults with established heart disease and who are also overweight or obese. Similarly, Zepbound’s approval for treating moderate-to-severe obstructive sleep apnea in adults with obesity has opened the door for coverage when prescribed for that specific medical condition. If your medical records only show a diagnosis of being overweight, coverage will not be granted.

Q3. How do I apply for the 2026 Medicare weight loss drug pilot program?

You do not “apply” for the 2026 Medicare weight loss drug pilot program as a separate enrollment process. This pilot is an expansion of the existing Medicare Part D benefit, designed to make these medications accessible to a subset of beneficiaries by reducing the cost to Medicare and establishing a maximum beneficiary copay of $50. The coverage expansion is determined by your enrollment in a participating Medicare Part D plan and your doctor’s medical records. To qualify, your physician must document that you meet the pilot program’s specific criteria—such as having severe obesity (a BMI greater than 35) or being overweight (a BMI greater than 27) with a qualifying comorbidity like cardiovascular disease or prediabetes. The most important step to take is to review your current Part D plan’s 2026 formulary during the annual Open Enrollment period (October 15 to December 7) to ensure your specific drug is listed and that you understand the plan’s Prior Authorization requirements.

Final Takeaways: Mastering Medicare Weight Loss Drug Access in 2026

The shift in Medicare Part D coverage for GLP-1 medications, such as Wegovy and Zepbound, marks a historic change, moving from a complete statutory exclusion to a targeted, low-cost pilot program for beneficiaries with obesity and related conditions. This is the single most important development: direct coverage for weight loss drugs under Medicare Part D will begin in mid-2026, offering eligible beneficiaries a maximum monthly copay of just $50. This significant reduction from the typical out-of-pocket costs exceeding $1,000 per month is projected to be a game-changer for approximately 10% of Medicare enrollees, a figure cited in the White House’s announcement of the GENEROUS model.

3 Essential Actionable Steps to Prepare for 2026 Coverage

To ensure you are ready to take advantage of this landmark coverage in 2026, you must begin preparing now.

  1. Get a Medically Necessary Diagnosis: Coverage is indication-specific. Do not wait for the pilot program to launch to establish the medical necessity of treatment. Work with your primary care provider or specialist to get a clear, documented diagnosis of a qualifying condition, such as severe obesity (BMI $>35$) or a BMI $>27$ with a specific comorbidity like established cardiovascular disease. Having this clinical documentation on file will expedite the Prior Authorization process required by most Part D plans.
  2. Understand Your Current Drug Protocol: If you are currently taking an older generation GLP-1 (like Ozempic or Mounjaro) for a diabetes or cardiovascular risk reduction indication, note that its coverage remains secure. If you plan to switch to a newer, weight-loss-specific drug, be prepared to meet the new, strict eligibility criteria when the Part D pilot begins.
  3. Review the $50 Copay and $2,100 Cap: Remember that the Inflation Reduction Act caps your total annual out-of-pocket spending on covered Part D drugs at $2,100 starting in 2026. This cap, combined with the new $50 maximum monthly copay for the covered GLP-1s under the pilot program, should give you a clear, predictable ceiling on your drug expenses.

What to Do Next: Reviewing Your Part D Plan

The final, and most critical, actionable step is to Review your current Medicare Part D plan during the next Open Enrollment period (October 15 to December 7). You must not assume your existing plan will automatically cover these new medications under the pilot program.

Use the Medicare Plan Finder tool at Medicare.gov starting in October 2025 to compare the 2026 Part D formularies in your area. You need to verify two things: that the specific weight-loss drug (e.g., Zepbound or Wegovy) is listed on the plan’s formulary and what the plan’s specific Prior Authorization (PA) and Step Therapy (ST) criteria are for that medication. Selecting the right Part D plan in the fall of 2025 is your key to unlocking the new, affordable coverage starting in 2026.