GLP-1 coverage can feel complex. This guide gives you the short answer and the steps to check your plan. You’ll see when a GLP-1 may be covered and what that means for your costs in 2025. Use it to talk with your doctor and make a safe, budget-smart choice.
Key Takeaways
- Medicare Part D excludes drugs used only for weight loss.
- GLP-1s may be covered for FDA-approved uses other than weight loss, such as Type 2 diabetes, cardiovascular risk reduction or obstructive sleep apnea.
- Coverage varies by plan and depends on the Drug List (formulary) and rules like prior authorization, step therapy and quantity limits.
- In 2025, Part D caps yearly out-of-pocket costs for covered drugs at $2,000. Coinsurance and deductibles can still apply until you hit the cap.
- Medicare also covers services that support weight management, including obesity counseling under Part B when you qualify.
Thinking about Medicare Advantage and GLP-1 Coverage?
Call us for personalized plan details like Drug List status, costs, and next steps for your medications.
What are GLP-1 Medications?
GLP-1 medicines help your body control blood sugar and can lower appetite. They signal your pancreas to release insulin when needed, slow how fast food leaves your stomach and reduce sugar made by your liver. Doctors mainly prescribe them for Type 2 diabetes. Some brands also have approvals to lower heart risk in certain adults or to treat obstructive sleep apnea.
Most are once-weekly injection at home; common side effects include:
- Nausea
- Diarrhea
- Constipation
Your doctor can help you find a safe, affordable option.
Medicare may cover these drugs only when used for an FDA-approved reason other than weight loss, and coverage depends on your plan’s Drug List (formulary) and any rules like prior authorization.
What Medicare Covers Today
Weight-loss-only prescriptions are excluded from Medicare Part D coverage. This includes drugs whose only use is weight management. Plans cannot cover them for that purpose.
When coverage may be possible: If a medication has an FDA-approved indication beyond weight loss, Part D plans may cover it for that specific use. Examples include:
- Wegovy™ (semaglutide) to reduce the risk of cardiovascular death, heart attack or stroke in adults with cardiovascular disease who are overweight or obese.
- Zepbound™ (trizepatide) for moderate to severe obstructive sleep apnea in adults with obesity.
- GLP-1s for Type 2 diabetes, such as Ozempic™, Rybelsus™, Trulicity™, Victoza™ and Mounjaro™ when used for blood sugar control. Coverage still depends on your specific plan’s Drug List (also known as a formulary) rules.
Coverage decisions are indication-specific. A drug may be covered for one use but not for weight loss. Your plan may have extra rules.
If prior authorization is needed, start with your doctor. They will send your plan a request with a letter of medical necessity and medical records that show:
- Your diagnosis and the FDA-approved reason for the drug
- Recent notes, labs, or measurements (for example, A1C, BMI, heart disease or sleep apnea details)
- What you have already tried and why it didn’t work or wasn’t safe
Your plan reviews the request and sends a decision to you, your doctor, and your pharmacy. If step therapy applies, you may need to try a covered alternative first. If medical limits apply, your doctor can ask for an exception and explain the medical reason.
At-a-Glance: Common Medications and Typical Medicare Coverage
|
Medication |
FDA-Approved Uses Relevant to Medicare |
Typical Medicare Coverage Status |
|
Wegovy™ (semaglutide) |
Chronic weight management; reducing cardiovascular (CV) risk in adults with CV disease plus overweight or obesity |
May be covered for CV-risk reduction if on formulary and criteria met; not covered for weight loss alone |
|
Ozempic™ (semaglutide) |
Type 2 diabetes |
May be covered for Type 2 diabetes if on formulary; not covered for weight loss. |
|
Rybelsus™ (semaglutide, oral) |
Type 2 diabetes |
May be covered for Type 2 diabetes if on formulary; not covered for weight loss. |
|
Mounjaro™ (trizepatide) |
Type 2 diabetes |
May be covered for Type 2 diabetes if on formulary; not covered for weight loss. |
|
Zepbound™ (trizepatide) |
Chronic weight management; obstructive sleep apnea(OSA) in adults with obesity |
May be covered for OSA indication if on formulary; not covered for weight loss alone. |
|
Trulicity™ (dulaglutide) |
Type 2 diabetes |
May be covered for Type 2 diabetes if on formulary; not covered for weight loss. |
|
Victoza™ (liraglutide 1.8 mg) |
Type 2 diabetes |
May be covered for Type 2 diabetes if on formulary; not covered for weight loss. |
|
Saxenda™ (liraglutide 3 mg) |
Chronic weight management |
Not covered for weight loss under Part D’s exclusion. |
Note: Coverage and tiers vary by plan and state. Always check your plan’s specific Drug List (formulary).
What You Might Pay: How Medicare Drug Costs Work in 2025
Your costs depend on your specific plan, the pharmacy you use and whether your medication is covered for your diagnosis. In 2025, Medicare Part D caps out-of-pocket costs for covered drugs at $2,000; until you reach that cap, many higher-cost medicines fall on specialty tiers with coinsurance.
- Deductible — Plans can have a deductible up to $590. You pay 100% for covered drugs until you meet it. Some plans have a lower or $0 deductible.
- After the Deduction — You generally pay 25% coinsurance for covered drugs until you reach the annual $2,000 out-of-pocket maximum. Once you hit the cap, you pay $0 for covered Part D drugs for the rest of the year.
- Drug Tiers Matter — High-cost medicines are often on a "specialty" tier. Plans can set specialty-tier coinsurance between 25% and 33% depending on the plans deductible. Many GLP-1s fall on higher tiers.
- Special Cases — Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are $0, and covered insulin is capped at $35 for a one-month supply. These rules are separate from GLP-1 coverage.
Note: The $2,000 cap and the above rules apply only to covered Part D drugs. If a drug is not covered for your diagnosis, Part D cost rules (including the cap) do not apply.
Weight Loss Alternatives Covered by Medicare
Even if a medicine isn’t covered for weight loss, Medicare still pays for several services that help manage weight and related conditions. These benefits, when medically necessary, can work on their own or alongside medications used for other approved diagnoses.
- Obesity Counseling Under Part B — Medicare covers intensive behavioral therapy when you have a Body Mass Index (BMI) of 30 or more and you receive counsel from a primary care practitioner in a primary care setting. Coinsurance and the Part B deductible are waived for this service.
- Medical Nutrition Therapy — Covered under Part B if you have diabetes or kidney disease and are referred by your doctor.
- Bariatric Surgery — Covered for certain conditions when medical criteria are met. Talk to your care team about whether you qualify.
How to Talk to Your Doctor About Weight Loss Medication
To make the most of your next appointment and help your doctor match treatment to your plan, go prepared. Bring the following info to your visit:
- Your diagnosis and other conditions, like cardiovascular disease or obstructive sleep apnea
- What you’ve tried already, and any side effects.
- Your plan details and Drug List results. Ask whether your medical history supports an FDA-approved indication that your plan may cover.
When Will Medicare Cover Weight Loss Drugs
The Centers for Medicare & Medicare Services (CMS) is exploring a pilot that could allow some Medicaid programs and Part D plans to cover GLP-1 drugs for “weight management,” with potential Medicare availability in 2027. Details are not finalized and would go through public processes. Which means today’s rules still apply.
How Wellcare Medicare Advantage Plans Fit In
Many Wellcare Medicare Advantage plans include Part D drug coverage. These plans follow Medicare Part D rules, which means weight-loss-only drugs remain excluded, but drugs may be covered for other FDA-approved indications if they are on the plan’s Drug List and criteria are met.
Always check your plan’s Drug List and specific drug requirements.
Next Steps: How to Check Your Medicare Drug Coverage for GLP-1 Medications
- Search the Drug List — Look up the drug name and dose to see if it’s covered and on which tier.
- Review any Requirements — See if prior authorization, step therapy or quantity limits apply.
- Ask Your Prescriber for Documentation — For covered indications, your doctor may need to provide diagnosis details, relevant labs and notes showing you meet your plan’s criteria (Remember, requirements vary by plan)
Thinking about Medicare Advantage and GLP-1 Coverage?
Call us for personalized plan details like Drug List status, costs, and next steps for your medications.
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Frequently Asked Questions (FAQs)
Does Medicare Cover Weight Loss Drugs?
No. Medicare Part D excludes drugs used for weight loss. Some of these medications may be covered for other FDA-approved medical uses that are not weight loss, depending on your plan.
Do Wellcare Medicare Advantage plans cover Ozempic, Mounjaro or Trulicity?
They may cover these medicines for Type 2 diabetes if the drug is on your plan’s Drug List and you meet the plan criteria. They are not covered for weight loss. Check your specific plan’s Drug List.
Is Ozempic Covered by Medicare?
In some cases. Medicare Part D plans may cover Ozempic, when it’s prescribed for Type 2 diabetes and listed on your plan’s Drug List (formulary). It is not covered for weight loss. Always check your plan for prior authorization, step therapy or quality limits. Or call the number on your member ID card.
Is Wegovy Covered by Medicare?
Wegovy may be covered only when prescribed to reduce cardiovascular risk in adults with established cardiovascular disease who are overweight or obese, and only if your plan lists it on the Drug List. It is not covered for weight loss alone.
Is Zepbound Covered by Medicare?
Zepbound may be covered when prescribed to treat obstructive sleep apnea in adults with obesity, if your plan lists it and criteria are met. It is not covered for weight loss alone.
Can a Doctor Prescribe a Drug “Off-Label” and Have Medicare Cover It?
Part D coverage generally follows FDA-approved and other musically accepted indications. Drugs used for weight loss remain excluded even if prescribed off-label. Your plan will review clinical documentation if prior authorization is required.
What if My Drug is Not on the Drug List?
Ask your prescriber about alternatives on your plan’s Drug List or whether a formulary exception may be appropriate. Decisions are made case-by-case.
Are There Programs to Help with Medication Costs?
Yes. Many members qualify for Extra Help or state assistance programs that lower drug costs. Your pharmacist or plan can help you check your eligibility. (Program availability varies by state.)
When Will Medicare Cover Weight Loss Drugs?
There is no set date. CMS is exploring a pilot that could let some Medicare Part D plans cover GLP-1s for weight management in the future, with Medicare participation as early as 2027. Details are not final, so today’s rules still apply.
Sources
- Lilly.com: Zepbound medication guide
- Lilly.com - Mounjaro medication guide
- FDA.gov - Wegovy prescribing information
- FDA.gov - Victoza prescribing information
- FDA.gov - Rybelsus prescribing information
- FDA.gov - Trulicity prescribing information
- FDA.gov - Ozempic prescribing information
Wellcare is the Medicare brand for Centene Corporation, an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal.
“Wellcare” is issued by WellCare Prescription Insurance, Inc.
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