Does Medicare Cover GLP-1 for Weight Loss?

Glucagon-like peptide-1 (GLP-1) medications, such as Wegovy, Ozempic, and Mounjaro, have become widely discussed due to their effects on blood sugar regulation and appetite. These medications mimic natural hormones in the body that help manage glucose levels and can also lead to significant weight reduction. Many individuals exploring these treatments often wonder about Medicare’s coverage policies, particularly when the primary goal is weight loss.

Medicare’s General Policy on Weight Loss Medications

Medicare’s stance on covering medications primarily for weight loss is defined by federal law. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 specifically excludes prescription drugs when their sole or primary use is for anorexia, weight gain, or weight loss from Part D coverage. If a drug is prescribed purely for weight management, Medicare Part D plans generally cannot cover it. The rationale behind this exclusion has historically been rooted in a view that weight loss was often considered a lifestyle or cosmetic concern rather than a medical condition requiring pharmaceutical intervention. Therefore, medications whose only purpose is weight reduction are typically not eligible for coverage under Medicare’s prescription drug benefit.

GLP-1 Medications and Covered Health Conditions

While Medicare generally does not cover medications prescribed solely for weight loss, a crucial distinction exists for GLP-1 drugs. Many of these medications are approved by the Food and Drug Administration (FDA) for conditions other than weight management, such as Type 2 Diabetes or cardiovascular disease. When a GLP-1 medication is prescribed for one of these Medicare-covered conditions, it may be eligible for coverage under Medicare Part D, even if weight loss is a beneficial side effect.

For instance, Ozempic (semaglutide) is FDA-approved to manage blood sugar levels in adults with Type 2 Diabetes and to reduce the risk of major cardiovascular events like stroke, heart attack, or death in adults with Type 2 Diabetes and established heart disease. Mounjaro (tirzepatide) is covered when prescribed for Type 2 Diabetes. Victoza (liraglutide) is another GLP-1 medication covered for Type 2 Diabetes and for reducing cardiovascular risk in certain patients.

Wegovy (semaglutide), while approved for chronic weight management, recently received an expanded FDA indication to reduce the risk of major cardiovascular events in adults with cardiovascular disease who are also obese or overweight. This new indication allows Medicare Part D plans to cover Wegovy for this specific cardiovascular risk reduction purpose, but not for weight loss alone. Therefore, coverage hinges on the medication’s FDA-approved use for a recognized medical condition, rather than its weight loss effect.

Understanding Medicare Part D Coverage

Medicare Part D provides prescription drug coverage through private insurance companies approved by Medicare. These plans vary, and each maintains a formulary, a comprehensive list of covered prescription drugs. The availability of a specific GLP-1 medication, even for a Medicare-covered condition, depends on its inclusion in a plan’s formulary.

Formularies organize drugs into tiers, with each tier corresponding to a different cost-sharing level. Generic drugs are usually in lower tiers with the lowest out-of-pocket costs, while brand-name or specialty medications, which often include GLP-1 drugs, may be in higher tiers with greater co-payments or co-insurance. Beneficiaries pay a portion of the drug’s cost, and this amount can differ significantly based on the tier. Each plan sets its own formulary and tier structure, impacting the final cost to the individual.

Navigating Coverage and Out-of-Pocket Costs

To determine specific coverage for GLP-1 medications, review your Medicare Part D plan’s formulary, found online or by contacting the plan directly. This confirms whether the prescribed GLP-1 drug is covered for its FDA-approved medical indication. Many high-cost or specialty medications, including GLP-1 drugs, often require prior authorization. Your prescribing doctor must provide justification that the medication is medically necessary for an approved condition.

Some plans may also implement step therapy, requiring patients to try a less expensive or alternative drug first before a more costly option is covered. Beneficiaries typically pay an annual deductible before their plan begins to contribute to drug costs. After meeting the deductible, an initial coverage period follows where co-pays or co-insurance apply.

A significant change for 2025 is the elimination of the coverage gap, often called the “donut hole,” and the introduction of a $2,000 annual out-of-pocket spending cap for covered Part D drugs. Once this out-of-pocket maximum is reached, beneficiaries pay nothing for covered medications for the rest of the calendar year. For personalized information, consult with your prescribing physician and your Medicare Part D plan directly.