No, Medicare won't cover weight-loss drugs solely for weight loss in 2025, but a significant pilot program (BALANCE) starts in mid-2026, expanding coverage for some seniors with obesity and related conditions (like diabetes, heart disease) via Part D, with costs potentially as low as $50 monthly, thanks to deals with drugmakers for price cuts. Currently, coverage only exists if the GLP-1 drug (like Ozempic/Mounjaro) is for Type 2 diabetes or heart risk.
Medicare generally won't cover Wegovy (semaglutide) for weight loss alone in 2025, due to federal law, but it may be covered in 2026 through pilot programs for certain conditions like heart disease, diabetes, or severe obesity, depending on the specific plan and FDA-approved uses. Coverage for 2025 hinges on an approved use other than weight loss, such as reducing cardiovascular risk, requiring your Part D plan to list it on its formulary and meet criteria like prior authorization.
Medicare does not cover weight-loss drugs prescribed solely for weight loss, due to federal law. However, it may cover drugs like Wegovy (semaglutide) or Zepbound (tirzepatide) if they have FDA approval for other serious conditions, such as reducing cardiovascular risk or treating obstructive sleep apnea, and are prescribed for those specific uses, opening doors for broader coverage as new approvals emerge.
In 2026, the limit on out-of-pocket prescription drug spending will increase to $2,100, up from $2,000 in 2025. Once beneficiaries pay a plan's full deductible, they will owe 25% of the cost of coinsurance until the $2,100 cap is reached.
To get Zepbound coverage through Medicare, you must have a moderate to severe obstructive sleep apnea diagnosis and a BMI of 27 or higher. You must also have either Medicare Part D drug coverage or a Part C (Medicare Advantage) plan that includes Part D coverage.
Yes, the Medicare Part D "donut hole" (coverage gap) is officially eliminated as of January 1, 2025, thanks to the Inflation Reduction Act, simplifying coverage into three phases: deductible, initial coverage, and catastrophic, with a new $2,000 out-of-pocket spending cap that eliminates the gap where higher costs used to occur.
Federal law bans weight-loss drug coverage in Medicare. GLP-1s treat heart disease, diabetes. Valued for weight loss. Some Part D plans pay for Ozempic, Wegovy, Zepbound.
2026 Savings Card — Now Available
The Zepbound Savings Card has been renewed for 2026 (expires December 31, 2026). Note: Terms have changed from 2025: With coverage: As low as $25/fill, $100/month max savings (was $150), $1,300/year cap (was $1,950)
If you don't have insurance or your commercial insurance doesn't cover Wegovy®, NovoCare® Pharmacy offers it for $199 per month to those on their first two months of taking Wegovy at the 0.25 mg and 0.5 mg doses. Thereafter, the price goes up to $349 per month for all doses.
The extra $144 added to Social Security usually comes from the Medicare Part B Giveback benefit, offered by some Medicare Advantage (Part C) plans, which pays back some or all your Part B premium, showing up as extra money in your check if it's deducted from your Social Security. To qualify, you need Original Medicare (Parts A & B), pay your own Part B premium, live in a plan's service area, and enroll in a specific Medicare Advantage plan that offers this "rebate," with the amount varying by plan and location.
Tips on How to Avoid the Donut Hole Coverage Gap
Discuss lower-cost drug alternatives with your healthcare professionals. Seek out discounts on medications. Choose generic drugs over brand-name drugs. Opt for in-network pharmacies only.
In 2026, the Centers for Medicare and Medicaid Services (CMS) is ending a program called the Value-Based Insurance Design (VBID) model. This program helped health plans give extra non-medical benefits, like credits for healthy food and utilities.
Last updated on Oct 3, 2025. Medicare generally does not cover Zepbound for weight loss as of 2025, though limited exceptions may exist for obstructive sleep apnea (OSA) depending on individual plan formulary and medical indication.
Zepbound (tirzepatide) is covered by many insurance plans and Medicare for its FDA-approved uses: chronic weight management in adults with obesity (BMI ≥ 30) or overweight (BMI ≥ 27) with at least one weight-related condition (like high blood pressure, high cholesterol, or type 2 diabetes) and for moderate to severe obstructive sleep apnea (OSA) in adults with obesity, in conjunction with diet and exercise. Coverage depends heavily on your specific insurer, plan, and meeting clinical criteria, requiring prior authorization and documentation, especially for Medicare, which covers OSA but generally not weight loss alone.
The coverage for weight loss under the BALANCE Model will launch in Medicaid as early as May 2026 and in Medicare Part D in January 2027. However, Medicare Part D beneficiaries are expected to have access to GLP-1s by July 2026 through a separate short-term demonstration that will serve as a bridge to BALANCE.
Costco offers a four-week supply of Wegovy (and Ozempic) for a self-pay price of around $499 for members with a prescription through their Member Prescription Program, a significant discount from typical retail prices, with potential extra savings for Executive Members and cardholders, though prices can vary slightly and you should always check with your local pharmacy for exact figures.