The Medicare Prescription Drug, Improvement, And Modernization Act Of 2003 directs that Medicare Part D (outpatient) plans cannot cover drugs used for weight loss. It is notable though that obesity screening, behavioral counseling and bariatric surgery are covered. So, in the strictest sense, you will not be able to obtain coverage from your Part D plan for drugs like Wegovy (semaglutide, Novo Nordisk) or Zepbound (tirzepatide, Eli Lilly).
Wegovy to be made available under Medicare Part D plans
The weight loss injectable drug Wegovy (semaglutide) received FDA (Food and Drug Administration) approval in March 2024 for a supplemental cardiovascular indication. This has huge implications for health plans operating Medicare Part D programs. It now means patients who meet weight and major cardiovascular risk criteria can obtain coverage for Wegovy. Since Zepbound does not have a supplemental cardiovascular FDA approved indication, it cannot be covered.
Therefore, if you have Medicare Part D outpatient coverage and you are overweight or obese and have pre-existing (severe) cardiovascular disease, then you may be covered under your plan. But remember, because Wegovy is not designated as one of the six protected drug classes, the plans do not have to include Wegovy into its formulary of reimbursable drugs.
This means that plans are most likely to take a cautious approach to approvals and require prior authorizations, especially because Wegovy is extremely expensive, with a list price of around $16,200 for a one-year supply.
Medicaid coverage or Zepbound & Wegovy
Medicaid can cover weight loss drugs, however, only 20% of state Medicaid agencies currently provide this coverage. You should check with your state Medicaid program to see if they offer Zepbound or Wegovy coverage.
Since Wegovy has received its supplemental FDA indication, all Medicaid agencies will now be obligated to place it on their lists of reimbursable drugs. However, they can still require patients to follow step edits (trying cheaper alternatives first) before they can obtain Wegovy for the cardiovascular indication.
