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 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.
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:
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.
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
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:
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."
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:
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."
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:
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."
With Medicare coverage officially off the table for 2026, your clients who want these medications specifically for weight loss have limited options:
This story isn't over. Here's what to keep an eye on:
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:
Visit this page for MedicareCENTER training videos.
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.