Weight Loss Drugs Medicare Covers For Seniors (If They Meet One Important Criteria)

Medicare has a number of health benefits even with its 2025 hike for seniors, but its rules block coverage for drugs used for weight loss or weight gain, per the Centers for Medicare & Medicaid Services (CMS) 2026 policy update. However, plans can cover the same drug if the Food and Drug Administration (FDA) has approved it for a different medical use. As CMS explains, a Part D plan can only pay for the drug if it is prescribed for another medically approved indication like type 2 diabetes or cardiovascular disease.

That exception is why Ozempic (semaglutide) and Mounjaro (tirzepatide) appear on Medicare drug lists, while their high-dose versions, Wegovy and Zepbound, which are marketed for weight loss, are left out. Zepbound now qualifies for Medicare coverage in some cases because the Food and Drug Administration (FDA) approved it on December 20, 2024 to treat moderate-to-severe obstructive sleep apnea. A Part D plan can cover the drug if the prescription is for sleep apnea, even though its well-known use for weight control is still blocked under Medicare rules. In short, a medically accepted use for weight loss transforms a denied claim into a covered benefit. Medicare applies a similar yardstick to cosmetic surgery, which is not covered unless specific conditions are met.

Ozempic and Mounjaro appear on Medicare drug lists because they're approved to treat type 2 diabetes. According to GoodRx's Medicare data, based on CMS plan files, 94% of stand-alone Part D and Medicare Advantage drug plans covered Ozempic in 2024, and 91% covered Mounjaro, rates similar to older insulin drugs. This coverage is tied to their FDA-approved use for blood sugar control, which gives plans the legal reason to approve the claim.

This is good news because in 2025, the Inflation Reduction Act set a $2,000 yearly cap on drug spending. After that, the remaining costs for covered drugs are picked up by the plan and Medicare. The Centers for Medicare & Medicaid Services (CMS) confirmed the new limit in its July 29, 2024, Part D bid fact sheet. That means retirees who hit the cap early in the year will pay nothing more for the rest of it.

Plans still require prior approval and limit how much you can get because spending has increased. The Kaiser Family Foundation reported $4.6 billion in Part D spending on Ozempic in 2022 alone, a 77% increase in one year, making it the sixth most expensive drug in the program. Most plans ask for proof of a diabetes diagnosis and may reject claims that only mention weight loss. But for seniors who meet the medical rules, strong plan coverage, and the new out-of-pocket cap now make these once-pricey injectables easier to afford.

Wegovy's March 2024, FDA approval made it useful for lowering heart-attack and stroke risk in adults with obesity. That gave Medicare Part D plans the legal ground to cover it for that condition, but adoption has been slow. An August 2024 Reuters review of CMS formulary files found only about 1% had added Wegovy for its new heart-related use. Zepbound could move faster. The Food and Drug Administration (FDA) approved it on December 20, 2024 to treat moderate-to-severe obstructive sleep apnea and clinical data from Lilly in 2024 shows the drug can reduce apnea episodes by 63%. With an approved medical use for sleep apnea, it meets Medicare's rule against paying for weight-loss drugs.

With an approved medical use, a Medicare Part D plan can start covering Zepbound once its pharmacy and therapeutics committee votes to add it to the list. Centers for Medicare & Medicaid Services (CMS) rules say these committees must review any new drug or new use within 90 days and decide on coverage within 180 days. That means a plan could add Zepbound, as long as the sleep apnea use is already on the label.