Medicare's Coverage of Weight Loss Drugs

Medicare Part D (prescription drug coverage) covers some weight loss medications, but not all of them, and coverage rules vary by plan and by drug. The most commonly covered weight loss drugs are older medications like phentermine and diethylpropion, which have been on the market for decades. Newer drugs like semaglutide (Ozempic, Wegovy) and tirzepatide (Zepbound, Mounjaro) are covered by some Part D plans but not others — and some plans may require you to try an older drug first before they will cover a newer one.

Medicare Part B does not cover weight loss drugs as a standalone benefit. Part B covers certain medications when they are given in a doctor's office or hospital setting, but weight loss medications are typically self-injected or taken by mouth at home, so they fall under Part D instead. If you have Original Medicare (Part A and Part B) without a Part D plan, you will pay the full retail price for any weight loss medication unless you sign up for Part D coverage.

Key Takeaways

  • Medicare Part D covers weight loss drugs, but which ones and how much you pay depends on your specific plan's formulary — the list of covered medications.
  • Newer weight loss drugs like semaglutide and tirzepatide are not covered by all Part D plans, and some plans require prior authorization or a step therapy (trying an older drug first).
  • Your out-of-pocket cost for a covered weight loss drug depends on your plan's deductible, copay or coinsurance, and whether the drug is in a higher cost tier.
  • You can switch to a different Part D plan during the annual enrollment period (October 15 to December 7) if your current plan does not cover the drug your doctor recommends.
  • If Medicare does not cover the drug you need, some manufacturers offer patient information programs that reduce or eliminate your cost.

How to Find Out What Your Plan Covers

The first step is to check your plan's formulary, which is the official list of drugs your plan covers. You can find this on your plan's website or by calling the customer service number on your Medicare card. When you call or search online, have the exact name of the drug ready — for example, "semaglutide" rather than just "weight loss medication" — because the same drug can be listed under different brand names (Ozempic is semaglutide for diabetes; Wegovy is semaglutide for weight loss).

The formulary will tell you whether the drug is covered and what tier it is on. Tier 1 drugs usually have the lowest copay, while Tier 4 or 5 drugs have higher copays or coinsurance. The formulary will also note if the drug requires prior authorization (your doctor must get approval from the plan before you fill the prescription) or step therapy (you must try a different drug first).

If your plan does not cover the drug your doctor wants to prescribe, you have two options: ask your doctor to prescribe a covered alternative, or switch to a different Part D plan during the annual enrollment period. You cannot switch plans outside of enrollment unless you have a may have access to life event, such as losing employer coverage or moving to a different state.

What You Will Pay Out of Pocket

Your cost for a weight loss drug depends on where you are in your plan's coverage phases. When you first fill prescriptions each year, you pay your plan's deductible (usually $100 to $500, depending on the plan). After you meet the deductible, you pay a copay (a fixed dollar amount per prescription) or coinsurance (a percentage of the drug's cost), depending on what tier the drug is on.

Once you and your plan have spent a combined total of $5,850 on covered drugs in 2024 (this amount changes each year), you enter the coverage gap, sometimes called the "donut hole." In the gap, you pay a larger share of the drug's cost — typically 25 percent of the cost for most drugs, though the exact percentage varies. After you spend $8,550 out of pocket in 2024, you reach catastrophic coverage, where you pay only a small copay or coinsurance for the rest of the year.

Weight loss drugs are expensive. A month's supply of semaglutide or tirzepatide can cost $900 to $1,500 before insurance. Even with insurance, your copay or coinsurance could be $100 to $400 per month, depending on your plan and which coverage phase you are in. Some plans offer copay information programs that cap your out-of-pocket cost at a certain amount per month.

Prior Authorization and Step Therapy Requirements

Many Part D plans require prior authorization before they will cover a newer weight loss drug. This means your doctor must submit a request to the plan explaining why the drug is medically necessary for you. The plan then reviews the request and either approves it or denies it. This process usually takes 24 to 72 hours, though urgent requests can be reviewed faster.

Some plans use step therapy, which means you must try a covered drug from an earlier generation first — usually phentermine or another older medication — before the plan will cover a newer drug like semaglutide. If the older drug does not work for you or causes side effects, your doctor can request an exception, and the plan will then consider covering the newer drug. This process can add weeks to your treatment timeline.

If your plan denies coverage or requires step therapy and you disagree with that decision, you have the right to appeal. Your doctor can submit additional medical information to support the appeal, and you can request an expedited review if the delay would harm your health. The appeals process is free and does not require a lawyer.

Switching Plans to Get Coverage

If your current Part D plan does not cover the weight loss drug your doctor recommends, you can switch to a different plan during the annual enrollment period, which runs from October 15 to December 7 each year. The new coverage takes effect on January 1. You can compare plans on Medicare.gov by entering the drugs you take and seeing which plans cover them and at what cost.

When you compare plans, look not just at whether the drug is covered, but also at the copay amount, whether prior authorization is required, and whether the plan has a coverage gap. A plan with a lower monthly premium might have a higher copay for your specific drug, so calculate your total expected cost rather than comparing premiums alone.

If you miss the annual enrollment period, you cannot switch plans unless you have a may have access to life event. may have access to events include losing employer coverage, moving to a different state, becoming newly may be able to access for Medicare, or having a significant change in your income. If you experience a may have access to event, you have 60 days to switch plans.

Manufacturer information Programs

If Medicare does not cover your weight loss drug or your copay is too high, the drug's manufacturer may offer a patient information program. These programs can reduce or eliminate your out-of-pocket cost, depending on your income. Novo Nordisk (which makes semaglutide and tirzepatide) and Eli Lilly (which makes tirzepatide) both have information programs for patients with Medicare.

To learn about you may have access to, visit the manufacturer's website or ask your doctor's office. You will typically need to provide proof of income and Medicare enrollment. Some programs require that you have tried the drug through your insurance first, while others will help you pay even if your insurance does not cover it. The process process usually takes one to two weeks.

Be aware that using a manufacturer information program may affect your Medicare drug coverage in future years. Some programs count toward your out-of-pocket spending limit, while others do not. Ask the program administrator how the information will be reported to Medicare before you enroll.

Frequently Asked Questions

Does Medicare Part B cover weight loss drugs if my doctor gives them to me in the office?

No. Weight loss drugs are covered under Part D (prescription drug coverage) regardless of where you get them. If your doctor injects the drug in the office, you still need Part D coverage to pay for the medication itself. Part B covers the office visit and the injection service, but not the drug.

Can I get semaglutide or tirzepatide covered if my plan says it is not covered?

You can ask your doctor to request an exception, which the plan must review. If the plan denies the exception, you can appeal. You can also switch to a different Part D plan during the annual enrollment period. If neither option works, a manufacturer information program may help pay for the drug.

What if I cannot afford the copay even with insurance?

Check whether your plan offers copay information, which some plans do for expensive drugs. Contact the drug manufacturer to see if they have a patient information program. You can also ask your doctor about older, less expensive weight loss medications that your plan may cover with a lower copay.

Do I have to pay for weight loss drugs during the coverage gap?

Yes. During the coverage gap, you pay a larger share of the drug's cost — typically 25 percent. Once you reach catastrophic coverage (after spending $8,550 out of pocket in 2024), your copay drops to a small fixed amount. If the cost is too high, ask your doctor about switching to a covered alternative or contact the manufacturer about information.

Can I use GoodRx or another discount card with Medicare?

You cannot use a discount card or coupon at the same time as your Medicare Part D coverage. However, you can ask the pharmacy to run the prescription both ways and see which costs less. If the discount card price is lower, you can choose to pay out of pocket and use the discount card instead of using your insurance, though this will not count toward your out-of-pocket spending limit.