Medicare's Coverage of Weight Loss Medications

Medicare Part D (prescription drug coverage) covers some weight loss drugs, but not all of them, and coverage rules vary by plan. The drugs Medicare is most likely to cover are those originally developed to treat type 2 diabetes — primarily semaglutide (Ozempic, Wegovy) and tirzepatide (Zepbound, Mounjaro) — because they have a diabetes indication on their label. However, your specific plan decides whether to include these drugs, at what cost tier, and whether it will pay for them when prescribed for weight loss alone rather than diabetes.

Medicare Part B does not cover weight loss drugs. Part A (hospital care) does not cover them. The only path is through Part D, and even then, your plan's formulary (the list of drugs it covers) is the deciding factor. Two people on Medicare can have completely different coverage for the same drug depending on which Part D plan they chose during open enrollment.

Key Takeaways

  • Semaglutide and tirzepatide are the weight loss drugs most likely to be covered by Medicare Part D plans, though not every plan includes them.
  • Your Part D plan's formulary determines coverage, and you can view it on your plan's website or by calling the plan's customer service number.
  • Even if a drug is on your plan's formulary, you may face a prior authorization requirement, meaning your doctor must request approval from the plan before you fill the prescription.
  • If your plan does not cover the drug your doctor prescribes, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7).
  • Out-of-pocket costs for weight loss drugs on Medicare range widely depending on your plan's tier and deductible, from $0 to several hundred dollars per month.

How to Check What Your Plan Covers

The fastest way to find out whether your specific Part D plan covers a weight loss drug is to log into your plan's website and search the formulary by drug name. Most plans post their formularies online and update them annually. You will see the drug listed with a tier number (usually 1 through 5, with tier 1 being cheapest) and any restrictions — such as quantity limits or prior authorization requirements.

If you cannot find the formulary online or do not have internet access, call your plan's customer service number. The number is on your Medicare card. Have your plan name and the drug name ready. Ask three things: whether the drug is covered, what tier it is on, and whether your doctor needs to request prior authorization before you fill it. Write down the answers and the date you called.

If you are not yet on a Part D plan and are comparing plans before open enrollment, you can use the Medicare Plan Finder tool at Medicare.gov. Enter the drugs you take (or expect to take) and the tool will show you which plans cover them and at what cost.

Prior Authorization and Other Restrictions

Many Medicare Part D plans that do cover semaglutide or tirzepatide require prior authorization — meaning your doctor must submit a request to the plan and get approval before the pharmacy will fill your prescription. The plan may ask your doctor to document that you have tried other weight loss methods first, or that you meet certain criteria (such as a specific BMI or the presence of related health conditions).

Some plans also impose quantity limits, meaning they will only cover a certain number of doses per month or per year. Others may require you to pay a higher copay or coinsurance amount than you would for other drugs on the same tier. Check your plan's formulary for these details, or ask when you call customer service.

Prior authorization typically takes 3 to 5 business days. If your doctor's office submits the request, ask them for a timeline and whether they will contact you once it is approved. Do not assume the pharmacy has received approval — follow up with your doctor's office if you have not heard back within a week.

What to Do If Your Plan Does Not Cover the Drug

If your current Part D plan does not cover the weight loss drug your doctor prescribed, you have three options: pay out of pocket, ask your doctor about a different drug that your plan does cover, or switch to a different Part D plan.

Switching plans is only possible during the annual open enrollment period, which runs from October 15 to December 7 each year. During this window, you can drop your current plan and join a different one, effective January 1. Use the Medicare Plan Finder to see which plans in your area cover the drug you need and compare their costs. Keep in mind that plans change their formularies every year, so a drug your plan covers now may not be covered next year.

If you need the drug before open enrollment arrives, you can ask your doctor whether there is an alternative medication your current plan does cover. Some plans cover other weight loss drugs (such as phentermine or orlistat), though these are less commonly used than semaglutide or tirzepatide. Your doctor can also contact your plan to request a coverage exception, though plans rarely grant these for weight loss drugs prescribed for weight loss alone.

Out-of-Pocket Costs and Deductibles

The cost you pay for a weight loss drug depends on your plan's deductible, the drug's tier, and your plan's cost-sharing structure. If your plan has not yet met its deductible for the year, you may pay the full price of the drug until the deductible is satisfied. Once the deductible is met, you typically pay a copay (a fixed dollar amount) or coinsurance (a percentage of the drug's cost).

Weight loss drugs are often placed on tier 3 or tier 4, which means higher copays than tier 1 or tier 2 drugs. A single month's supply can cost anywhere from $50 to $400 or more out of pocket, depending on your plan. Some plans offer mail-order pricing that is lower than retail pharmacy pricing, so ask your plan whether that option is available.

Once you reach your plan's out-of-pocket maximum (the most you will pay in a year), the plan pays 100 percent of your drug costs for the rest of the year. The out-of-pocket maximum varies by plan but is capped by Medicare at a certain amount each year.

Medicare Advantage Plans and Weight Loss Drugs

If you are on a Medicare Advantage plan (Part C), drug coverage works differently. Medicare Advantage plans must cover at least as many drugs as Original Medicare Part D plans, but each Advantage plan sets its own formulary and cost-sharing rules. Some Advantage plans may cover weight loss drugs more generously than others, or may not cover them at all.

To check coverage under a Medicare Advantage plan, log into your plan's website or call the plan's customer service number. The process is the same as with Part D: ask whether the drug is covered, what tier it is on, and whether prior authorization is required. If your Advantage plan does not cover the drug you need, you can switch to a different Advantage plan or switch to Original Medicare with a Part D plan during open enrollment.

Frequently Asked Questions

Does Medicare cover Ozempic or Wegovy for weight loss?

Some Medicare Part D plans cover semaglutide (the active ingredient in both Ozempic and Wegovy), but not all. Your specific plan's formulary determines coverage. Ozempic is labeled for diabetes; Wegovy is labeled for weight loss. Plans may cover one, both, or neither. Check your plan's website or call customer service to find out.

Will my doctor's office help me find out what my plan covers?

Many doctor's offices will check your coverage before prescribing, especially if they know you are asking about a weight loss drug. Call your doctor's office and ask them to verify coverage with your plan. If they cannot, you can check yourself by logging into your plan's website or calling the plan's customer service number.

Can I get a weight loss drug if my plan does not cover it?

Yes, but you will pay the full cost out of pocket, which can be $300 to $1,000 or more per month depending on the drug and pharmacy. You can also ask your doctor about drugs your plan does cover, or wait until open enrollment to switch to a plan that covers the drug you want.

What if my plan covers the drug but my doctor says I need prior authorization?

Prior authorization is a common requirement. Your doctor's office will submit a request to your plan, which typically takes 3 to 5 business days to approve or deny. Ask your doctor's office for a timeline and follow up if you do not hear back within a week. Do not fill the prescription until authorization is approved.

Do I have to use a specific pharmacy to get the lowest cost?

Many plans offer lower copays at preferred pharmacies or through mail order. Check your plan's website or call customer service to see whether your pharmacy is in-network and whether mail order would cost less. Using an out-of-network pharmacy will likely cost you more.