Chronicle Central

One of the questions that keeps showing up again and again — from friends, neighbors, and folks we talk with — is pretty straightforward:

“Does Medicare cover Ozempic or other weight-loss drugs?”

It sounds simple, but the answer isn’t. Not because anyone wants to make it tricky, but because Medicare’s rules today treat these medications in ways that don’t always match what people think they mean when they hear “weight loss drug.”

Here’s the honest, down-to-earth version of what’s going on — without the confusing policy speak.

Right now, Medicare does not cover Ozempic, Wegovy, Zepbound, or similar drugs when they’re prescribed just for weight loss. That’s because the federal rules for Medicare Part D — the part that covers most prescription medications — specifically exclude drugs “used for weight loss.” 

So even if a doctor writes a prescription for one of these medications and you feel like you need it, the insurance coverage won’t kick in just because you want to lose pounds.

That can feel frustrating — especially when these drugs are talked about everywhere and people see them making a difference. But the coverage rules today don’t recognize weight loss alone as a reason to pay for them under Medicare Part D. 

Here’s where things get important: Medicare can cover these same drugs if they’re being used for other health reasons.

For example:

• Ozempic is covered when it’s prescribed for type 2 diabetes — that’s a standard Medicare Part D benefit.
   
• Some drugs in the same family are also covered when they’re prescribed to reduce cardiovascular risk in people who are overweight or have specific health conditions.
   

That means the same medication might be covered in one situation and not covered in another — depending on what it’s being treated for. That’s the legal dividing line Medicare uses. 

There’s a reason for this distinction, and it goes way back: the law that created Medicare Part D doesn’t allow prescription coverage for drugs used solely for weight loss. It’s a rule that has stayed in place even as medicine and understanding of obesity have changed. 

Because of this, even though medications like Ozempic, Wegovy, Zepbound and Mounjaro can help people lose weight — and are used that way by many — that specific use isn’t covered by Medicare right now unless there’s another qualifying medical reason. 

There has been ongoing discussion and some policy proposals aimed at changing this — for example, allowing coverage of weight-loss medications under Medicare Part D. However, as of now, Medicare’s official rules haven’t changed to allow coverage just for weight loss alone. 

There have been pilot programs and proposed models to test broader coverage in some cases in the years ahead, and negotiations around drug pricing might make these medications more affordable overall. But those developments are separate from the basic rule that governs what Medicare will pay for today. Reuters

So for now, even though there’s progress in some corners and debate among policymakers, the bottom line remains: Medicare doesn’t cover weight-loss prescriptions under Part D just because they help someone lose weight. 

If someone on Medicare is wondering about these medications, here’s the reality:

• If your doctor prescribes Ozempic or similar medications for diabetes or another approved medical condition, Medicare Part D may cover it — depending on your plan’s drug list and requirements.
   
• If the same medication is prescribed only for weight loss, Medicare Part D will not cover it.
   
• Coverage can vary from plan to plan, so checking the specific formulary and rules of your Medicare prescription plan is important.
   

Because drug coverage and formularies can vary, and because these medications are expensive for people paying cash, some folks look for:

• Manufacturer assistance programs
   
• Supplemental insurance that might cover more than basic Part D
   
• Other insurance sources outside of Medicare that have broader weight-loss drug coverage
   

But here’s the key takeaway that aligns with the facts:

Medicare’s prescription coverage does not — at this time — pay for these medications when their only purpose is to help you lose weight.