Medicare and GLP-1 Weight Loss Drugs: Ozempic, Wegovy, Mounjaro, and Zepbound

🔑 10 Key Takeaways (Quick Answers Before the Deep Dive)

Medicare cannot cover any GLP-1 drug prescribed solely for weight loss — this is a federal law from 2003, and it remains fully in effect through early 2026.

Ozempic and Mounjaro are covered by Medicare Part D when prescribed for type 2 diabetes — they must be on your specific plan’s formulary and are not covered for weight loss.

Wegovy is now covered by Medicare for cardiovascular risk reduction — the FDA officially approved Wegovy for reducing the risk of heart attack and stroke in people with cardiovascular disease, and Medicare Part D plans can now cover it for that specific purpose.

Zepbound is covered by Medicare for obstructive sleep apnea — the FDA has approved Zepbound for adults with moderate-to-severe obstructive sleep apnea who are also obese, creating a coverage pathway through Part D.

The BALANCE Model pilot program launches in July 2026 — CMS plans to implement a new Medicare GLP-1 payment demonstration beginning in July 2026, which will serve as a bridge program before full model launch in January 2027.

Eligible Medicare beneficiaries will pay just $50 per month under the new program — under the demonstration, eligible Medicare beneficiaries will pay $50 for a month of GLP-1 medications.

Medicare’s out-of-pocket drug cap is $2,100 in 2026 — Part D caps yearly out-of-pocket costs for covered drugs at $2,100, after which Medicare pays 100% for the rest of the year.

Medicare selected Ozempic, Wegovy, and Rybelsus for drug price negotiation — CMS selected Ozempic, Rybelsus and Wegovy for its second round of Medicare drug price negotiations, with negotiated prices of $274 for a 30-day supply effective in 2027.

The Wegovy oral pill was approved by the FDA in December 2025 — the first oral GLP-1 to gain federal approval for weight loss is also the lowest priced, with pharmacies stocking it in January 2026.

Roughly 10% of Medicare beneficiaries — about 7 million people — are expected to qualify under the expanded coverage through the BALANCE Model phased enrollment beginning mid-2026.

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🚫 Federal Law Still Bans Medicare From Covering Weight Loss Drugs — and That’s Not Changing Tomorrow

Before diving into the workarounds, exceptions, and pilot programs, every Medicare beneficiary needs to understand the foundational rule that governs everything else.

GLP-1 use for weight-loss only purposes are excluded from Medicare Part D coverage, meaning plans are not allowed to cover them for that purpose alone.

This isn’t a policy choice by individual insurance plans. It’s federal law. The Medicare Modernization Act of 2003 forbids Medicare from covering weight loss medications.

The Biden administration proposed reinterpreting this exclusion in November 2024. The proposed reinterpretation of Medicare coverage for anti-obesity medications is a critical inflection point in how the federal government approaches the treatment of obesity. However, on April 4, 2025, CMS released its final rule for Contract Year 2026 and officially decided not to include anti-obesity medication coverage, largely due to the enormous projected cost — estimated to cost Medicare about $25 billion over a decade, with the Congressional Budget Office projecting an additional $35 billion between 2026 and 2034.

So what changed? The Trump administration negotiated directly with drug manufacturers, creating an entirely different pathway.

📋 Timeline of Key Events	📅 Date	⚡ Impact
Medicare Modernization Act bans weight loss drug coverage	2003	Foundational federal prohibition enacted
Wegovy FDA-approved for weight loss	June 2021	Blocked from Medicare coverage by law
Wegovy approved for cardiovascular risk reduction	March 2024	🟢 Opens Medicare Part D coverage door for heart disease patients
Zepbound approved for sleep apnea	December 2024	🟢 Opens Medicare Part D coverage for sleep apnea patients with obesity
CMS rejects Biden proposal for 2026 AOM coverage	April 2025	Coverage expansion killed due to cost concerns
CMS selects Ozempic, Wegovy, Rybelsus for price negotiation	January 2025	Negotiated price of $274/month effective 2027
Wegovy oral pill FDA-approved	December 2025	First oral GLP-1 for weight loss hits pharmacies
CMS announces BALANCE Model	December 23, 2025	🟢 Pilot program for Medicare GLP-1 weight loss coverage
Medicare GLP-1 payment demonstration begins	July 2026 (planned)	$50/month copay for eligible beneficiaries
BALANCE Model full Medicare launch	January 2027 (planned)	Expanded Part D plan coverage of GLP-1s

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💉 The Complete GLP-1 Drug-by-Drug Medicare Coverage Breakdown — What’s Covered, What’s Not, and Exactly Why

This is the section that eliminates all confusion. Every GLP-1 drug has different FDA-approved indications, and Medicare coverage hinges entirely on which indication your doctor documents.

💊 Drug	🏭 Maker	✅ FDA-Approved For	❌ Not FDA-Approved For	🏥 Medicare Covers?
Ozempic (semaglutide injection)	Novo Nordisk	Type 2 diabetes; cardiovascular risk reduction; kidney disease	Weight loss (not FDA-approved for this)	✅ Yes — for diabetes, cardiovascular, kidney indications only
Mounjaro (tirzepatide injection)	Eli Lilly	Type 2 diabetes	Weight loss, sleep apnea (that’s Zepbound’s approval)	✅ Yes — for type 2 diabetes only
Wegovy (semaglutide injection/pill)	Novo Nordisk	Chronic weight management; cardiovascular risk reduction; MASH (liver disease)	—	✅ Yes — for cardiovascular risk reduction and MASH; ❌ No — for weight loss alone
Zepbound (tirzepatide injection)	Eli Lilly	Chronic weight management; moderate-to-severe obstructive sleep apnea with obesity	—	✅ Yes — for sleep apnea with obesity; ❌ No — for weight loss alone
Rybelsus (oral semaglutide)	Novo Nordisk	Type 2 diabetes	Weight loss	✅ Yes — for type 2 diabetes only
Saxenda (liraglutide)	Novo Nordisk	Chronic weight management	—	❌ No — only FDA-approved for weight loss
Victoza (liraglutide)	Novo Nordisk	Type 2 diabetes	Weight loss	✅ Yes — for type 2 diabetes only

Coverage decisions are indication-specific — a medication may be covered for one approved use but not for weight loss.

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❤️ Yes, Medicare Covers Wegovy for Heart Disease — but Your Doctor Must Document It Precisely

This is the single most important coverage development for Medicare beneficiaries who are overweight or obese with heart disease.

The most important change is that Medicare Part D may now cover Wegovy only when it is prescribed for cardiovascular risk reduction in patients with established heart disease who are overweight or obese.

That means the diagnosis code and medical documentation must clearly reflect cardiovascular disease — not weight management — as the treatment purpose.

Who qualifies? The new FDA-approved indication for Wegovy is targeted to people with established cardiovascular disease — meaning a prior heart attack, prior stroke, or peripheral arterial disease — and either obesity or overweight.

Based on KFF analysis of Medicare data, an estimated 3.6 million Medicare beneficiaries had established cardiovascular disease and obesity or overweight, making them potentially eligible.

But don’t assume automatic coverage. Even though Medicare can now cover Wegovy for heart disease, individual Part D plans still control their formularies. Plans may choose to include Wegovy, restrict it with prior authorization, or place it on a higher cost-sharing tier.

❤️ Wegovy for Heart Disease	📋 Key Details
🩺 Who qualifies?	Adults with established cardiovascular disease (prior heart attack, stroke, or peripheral arterial disease) who are overweight or obese
📝 Documentation needed	Diagnosis code must reflect cardiovascular disease, not weight management
💊 Covered under	Medicare Part D (self-administered injectable or oral pill)
⏳ Prior authorization?	Almost always required; expect documentation of cardiovascular diagnosis plus BMI
💰 Cost with Part D	Varies by plan tier; $2,100 annual out-of-pocket cap applies in 2026
💰 Negotiated price (2027)	$274 for a 30-day supply under Medicare drug price negotiations
🚫 Not covered for	Weight loss alone, even if you have obesity without documented heart disease

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😴 Medicare Now Covers Zepbound for Sleep Apnea — the Backdoor Path Nobody Expected

In December 2024, the FDA approved Zepbound as the first-ever medication to treat obstructive sleep apnea, creating a coverage pathway that didn’t exist just months earlier.

During clinical trials, participants reported an average weight reduction of 20% — close to 45 pounds — and experienced 25 fewer breathing interruptions every hour. Nearly 50% of volunteers saw a complete remission of OSA symptoms after one year.

Medicare can cover Zepbound when prescribed for moderate-to-severe obstructive sleep apnea in patients with obesity, but not when it’s prescribed only for weight loss.

Starting in April 2026, a government agreement sets the Zepbound copay at $50 per month for eligible Medicare patients.

😴 Zepbound for Sleep Apnea	📋 Key Details
🩺 Who qualifies?	Adults with moderate-to-severe obstructive sleep apnea and BMI of 27+
📝 Documentation needed	Sleep study confirming moderate-to-severe OSA; BMI documentation
💊 Covered under	Medicare Part D
⏳ Prior authorization?	Yes — almost universal; your doctor may prescribe CPAP therapy first, as it’s still the first-line treatment
💰 Cost (current)	Tier 4 or 5 (specialty tier) with coinsurance ranging from 25–33% until out-of-pocket cap
💰 Cost (April 2026+)	$50/month under government agreement
🚫 Not covered for	Weight loss alone; central sleep apnea; any use without obesity diagnosis

Here’s the insider tip that most articles won’t tell you: over 80% of Medicare Advantage prior authorization appeals succeed — yet only about 11% of patients ever appeal. If your initial Zepbound claim is denied for sleep apnea, appeal. The odds are overwhelmingly in your favor.

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🔮 The BALANCE Model Launches July 2026 — Medicare’s First-Ever Weight Loss Drug Coverage Program

This is the development that changes everything — but it’s not here yet.

CMS announced a new voluntary test of a model designed to enable Medicare Part D plans and state Medicaid agencies to cover GLP-1 medications used for weight management and metabolic health improvement, while helping control costs.

The BALANCE Model rolls out in two phases:

Phase 1 — Medicare GLP-1 Payment Demonstration (July 2026): A bridge program where beneficiaries enrolled in Medicare Part D who meet the negotiated access criteria will have access to these drugs at a $50 monthly copay. This operates outside the normal Part D benefit structure — meaning Part D plan sponsors carry no financial risk.

Phase 2 — Full BALANCE Model (January 2027 for Medicare): Part D plans voluntarily include GLP-1s in their formularies for weight management under the model’s terms.

Beneficiaries with Part D benefits will be phased into coverage in three stages: Phase 1 covers overweight individuals with BMI greater than 27 who have prediabetes or diagnosed cardiovascular disease. Phase 2 covers those with BMI greater than 30 who have uncontrolled hypertension, kidney disease, or heart failure.

🔮 BALANCE Model Timeline	📅 When	💊 Who Qualifies	💰 Cost to Beneficiary
Medicaid agencies can join	May 2026	Varies by state	Varies by state
Medicare GLP-1 payment demo	July 2026	BMI 27+ with cardiovascular disease or prediabetes	$50/month
Full Medicare Part D coverage	January 2027	Expanded — BMI 30+ with hypertension, kidney disease, or heart failure	~$50/month
Price negotiations take effect	2027	All Medicare beneficiaries with covered indications	$274/month (negotiated Wegovy/Ozempic price)

Copays for Medicare enrollees who use injectable Mounjaro, Ozempic, Wegovy, Zepbound or the Wegovy pill will be around $50 a month after any deductibles. The federal government will pay $245.

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💰 The Price Revolution: GLP-1 Costs Have Plummeted — Even Without Medicare Coverage

Even if you don’t qualify for Medicare coverage through any of the pathways above, the cash-pay landscape has transformed dramatically.

💊 Drug	💰 Price Without Insurance (2023)	💰 Self-Pay Price (Early 2026)	📉 Savings
Wegovy injection	$1,300+/month	$199/month (starting doses); $299+ for higher doses	Up to 85% reduction
Wegovy oral pill	N/A (not yet available)	$149/month for lowest doses; $349 for higher doses	First oral option
Ozempic injection	$900+/month	$199/month (starting doses)	~78% reduction
Zepbound injection	$1,060/month	$249–$499 depending on dose	Up to 76% reduction
Mounjaro injection	$1,023/month	$245/month (starting doses via government agreement)	~76% reduction

The site lists 43 brand-name drugs through TrumpRx and says more will be added. Consumers can get the prices at local pharmacies using TrumpRx coupons.

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🧩 What Medicare Already Covers for Weight Management (That Most Beneficiaries Don’t Know About)

While the GLP-1 coverage debate dominates headlines, Medicare already provides several weight management benefits that go widely unused:

Intensive Behavioral Therapy for Obesity (Medicare Part B): Medicare covers face-to-face obesity counseling for beneficiaries with a BMI of 30 or higher. This includes weekly visits for the first month, biweekly visits for months 2–6, and monthly visits for months 7–12 — all at no cost with a qualifying provider.

Medical Nutrition Therapy (Part B): Covered for beneficiaries with diabetes or kidney disease, providing personalized dietary counseling from a registered dietitian.

Diabetes Prevention Program (Part B): A structured year-long program for beneficiaries with prediabetes, covering coaching sessions focused on diet, exercise, and behavioral strategies.

Bariatric Surgery (Part A): Medicare covers Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding at certified facilities for beneficiaries with BMI 35+ and at least one obesity-related condition.

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❓ Frequently Asked Questions

Does Medicare cover Ozempic for obesity or weight loss?

No. Ozempic is covered when used for blood sugar control in patients with type 2 diabetes and its other FDA-approved indications. It is not FDA-approved for weight loss, and Medicare cannot cover it for that purpose. Ozempic contains the same active ingredient as Wegovy (semaglutide), but at different doses and with different approvals.

Is Mounjaro covered by Medicare for weight loss?

No. Mounjaro is FDA-approved only for type 2 diabetes and is covered by Medicare Part D exclusively for that indication. More than 90 percent of commercial and Part D plans cover Mounjaro for people with type 2 diabetes, but it cannot be prescribed under Medicare for weight loss. Mounjaro contains the same active ingredient (tirzepatide) as Zepbound.

Is Wegovy covered by Medicare Part B?

No. Because Wegovy is a self-administered injectable drug, coverage is provided under Part D, not Part B, which covers physician-administered drugs. The new Wegovy oral pill is also covered under Part D, not Part B.

When will Medicare fully cover weight loss drugs?

The BALANCE Model begins a bridge program in July 2026, with full Medicare Part D plan participation launching January 2027. However, this is a voluntary pilot — not all plans will participate, and eligibility criteria are still being finalized. CMS has not yet provided details on how a beneficiary would qualify, enroll, or access the demonstration. More information is expected.

What if my Medicare Part D plan denies coverage for Wegovy or Zepbound?

Appeal. Request a Coverage Determination Notice with the specific reason for denial. Then file an appeal within 120 days. Over 80% of Medicare Advantage prior authorization appeals succeed, but most patients never appeal. Also ask your prescriber if a formulary exception request is appropriate — this is a formal process where your doctor explains why no alternative drug on your plan’s formulary will work for your condition.

Can I use the TrumpRx program with Medicare?

If you’re still working or have prescription coverage outside of Medicare or other government programs, you have the option to buy through TrumpRx. However, the cash prices through TrumpRx are not designed to interact with Medicare Part D benefits. Beneficiaries should check whether their Part D plan offers better pricing before paying cash.

What will the new Wegovy pill cost on Medicare?

The Wegovy pill (daily oral tablet) hit pharmacies in January 2026. Self-pay prices start at $149/month for the lowest doses. Under the July 2026 Medicare demonstration program, eligible beneficiaries would pay $50/month for GLP-1 medications including the oral pill, pending manufacturer participation.

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🧠 Final Expert Verdict: The Coverage Maze Has Hidden Doors — Find Yours

The situation for Medicare beneficiaries seeking GLP-1 medications in 2026 is simultaneously more restrictive and more hopeful than at any point in the past two decades. Federal law still prohibits coverage for weight loss alone. But through expanded FDA approvals for cardiovascular disease, sleep apnea, liver disease, and kidney disease — combined with a pilot program launching mid-2026 — the practical pathways to coverage are multiplying rapidly.

Medicare expenditures on Ozempic alone exceeded $4 billion in 2022. Goldman Sachs has forecast a $100 billion worldwide market for obesity drugs by 2030. The financial forces reshaping this market are enormous, and the policy infrastructure is racing to catch up.

Here is the strategic playbook for Medicare beneficiaries in 2026:

If you have type 2 diabetes → Ask your doctor about Ozempic, Mounjaro, Rybelsus, or Victoza. These are covered by Part D today for diabetes management, and the weight loss benefits come as a documented medical side effect.

If you have heart disease and are overweight/obese → Ask your doctor to prescribe Wegovy specifically for cardiovascular risk reduction. Ensure the documentation reflects the cardiovascular indication, not weight management.

If you have obstructive sleep apnea and obesity → Ask your doctor about Zepbound. Coverage is available now through Part D, with a $50/month copay starting April 2026.

If you have obesity without another qualifying condition → Watch for the BALANCE Model enrollment details in early 2026. The July 2026 bridge program could make you eligible for $50/month GLP-1 access if you meet BMI and comorbidity criteria.

If none of the above applies → Explore self-pay pricing, which has dropped by up to 85% from 2023 levels. A Wegovy pill starting at $149/month or Zepbound at $249/month is a fraction of what these drugs cost just two years ago.

The worst strategy? Waiting in silence for “someday” Medicare coverage while your metabolic health deteriorates. Talk to your doctor now. Document every qualifying condition. And if your initial coverage request is denied — appeal. The system is built to reward persistence.