Updated April 17, 2025 with new developments
Weight loss medications like Ozempic, Rybelsus, and Wegovy continue making headlines—and your clients are taking notice. As these medications become more popular, Medicare beneficiaries will have questions about whether they're covered and what their options are.
Let's break down what you need to know about Medicare and weight loss medications now that CMS has made its decision for 2026.
The Big Decision: No Medicare Coverage for Weight Loss Drugs
The suspense is over. On April 4, 2025, CMS released its final rule for Contract Year 2026, and officially decided not to include anti-obesity medication coverage for Medicare and Medicaid beneficiaries.
This decision effectively kills the Biden administration's November 2024 proposal that would have expanded access to GLP-1 medications for approximately 3.4 million Medicare beneficiaries and 4 million Medicaid recipients with obesity.
CMS didn't provide a detailed explanation for the decision, but did note they may consider future policy options for anti-obesity medications "pending further review of both the potential benefits of these drugs including updated clinical indications, and relevant costs."
Reading between the lines? Cost was likely a major factor—the proposed coverage expansion was estimated to cost Medicare about $25 billion over a decade.
Why Are Clients Asking About These Drugs?
GLP-1 medications like Wegovy and Ozempic were originally developed to treat diabetes but are now widely prescribed for weight loss.
With obesity affecting over 40% of American adults, many Medicare beneficiaries are interested in them.
Beyond weight loss, new research suggests these drugs may also:
- Reduce the risk of heart disease
- Help with alcohol cravings
- Improve sleep apnea
Because of these potential benefits, the demand for Medicare coverage is growing—but as of now, weight loss alone isn’t enough to qualify for coverage.
What Medicare Does Cover
- Medicare Part B covers obesity screenings and behavioral therapy for beneficiaries with a BMI of 30 or higher.
- Medicare Part D may cover GLP-1 medications like Ozempic—but only if prescribed for diabetes or another approved condition.
- Medicare does NOT cover weight loss drugs unless prescribed for another approved condition.
Talking point for clients:
"Right now, Medicare doesn’t cover Wegovy or other weight loss drugs, but if you have diabetes or another qualifying condition, some plans may cover similar medications. Let’s check your Part D formulary."
Related: 2025 Part D Updates & Carrier Highlights
Expanding Approval for Other Conditions: The Back-Door Path
While Medicare won't cover these medications specifically for weight loss, they ARE covered when prescribed for approved conditions. And the list of approved conditions is growing:
- Novo Nordisk's Wegovy received FDA approval for reducing cardiovascular risk in March 2024
- Ozempic is being studied for sleep apnea
- More indications are expected in the coming years
This means some of your clients might still qualify for coverage—just not for weight loss alone.
Talking point for clients: "Even though Medicare won't cover these medications specifically for weight loss, if you have heart disease, diabetes, or other qualifying conditions, there might be coverage options available. Medical science keeps finding new benefits of these drugs beyond weight loss."
The Compound Medication Cutoff
Remember the compounded versions of semaglutide that were available during the shortage? That window is closing fast.
Since the FDA declared the Ozempic and Wegovy shortage resolved on February 21, 2025, pharmacies must stop making compounded versions within 60–90 days:
- State-licensed pharmacies must stop by April 22, 2025
- Outsourcing facilities must stop by May 22, 2025
This leaves only the brand-name options available—at full price for those using them for weight loss.
Talking point for clients: "If you've been using a compounded version of these medications, be aware that they'll no longer be available after late April or May, depending on the pharmacy. This means you'll need to switch to the brand-name versions, which could significantly impact out-of-pocket costs."
Price Negotiations Still in Play
There's a potential silver lining. The Inflation Reduction Act allows Medicare to negotiate drug prices, and Wegovy and Ozempic remain candidates for negotiation.
However, there's still uncertainty:
- The Trump administration will determine if negotiations move forward
- Even if negotiations happen, lower prices wouldn't take effect until 2027
- Negotiations would primarily benefit those who qualify for coverage under approved conditions, not for weight loss alone
Talking point for clients: "While Medicare is working to negotiate lower prices for these medications, any potential savings probably won't happen until 2027 at the earliest. And even then, they'll mainly benefit people who qualify for coverage under specific medical conditions."
What Other Options Do Your Clients Have?
With Medicare coverage officially off the table for 2026, your clients who want these medications specifically for weight loss have limited options:
- Check for commercial insurance coverage if they're on an employer plan in addition to Medicare
- Look into manufacturer assistance programs (though these often exclude Medicare beneficiaries)
- Consider whether they qualify under other medical conditions where the drugs are approved
- Prepare for self-pay costs of $350-1,350 per month
What Agents Should Watch for in 2025-2026
This story isn't over. Here's what to keep an eye on:
- New FDA approvals for additional conditions that could expand Medicare coverage eligibility
- Potential future policy reconsideration as CMS left the door open for reviewing the issue
- Drug price negotiation developments that could affect affordability
- State Medicaid decisions as individual states may choose to expand coverage
MedicareCENTER
If Medicare starts covering weight loss drugs—or if your clients qualify for coverage due to another condition—MedicareCENTER makes it easy to compare costs and coverage options.
If you’re not already using it, now’s the time!
It’s free for contracted agents and helps you:
- Check Part D formularies for covered medications
- Compare plans for clients asking about weight loss drug coverage
- Track updates on policy changes in real time
Visit this page for MedicareCENTER training videos.
Conclusion
While the CMS decision is disappointing for many hoping for expanded coverage, it's important to stay informed about the evolving landscape of these medications.
By understanding the current coverage rules, alternative pathways to access, and potential future developments, you can provide valuable guidance to your clients navigating this complex situation.
