Weight Loss Drugs & Medicare

TABLE OF CONTENTS

• Medicare GLP-1 Bridge Program:  Get Some Weight Loss Drugs for $50 Copay
• Key Dates
• What Drugs Are Included?
• Who May Be Eligible?
  • Potential Eligibility Criteria
• How Much Does It Cost?
• How Does the Program Work?
• Important Limitation
• What Happens After 2027?
• Official Sources
• Why doesn't a Medicare Part D plan cover weight loss meds for other FDA approved purposes?
• Medicare Part D plans may not cover any medications in the categories and classes not considered to be the most commonly prescribed.
• Alternative Methods for Obtaining Weight Loss Drugs
• Formulary Exceptions For Drugs Not Covered by Part D Plans

It can be very frustrating when medications you take are not covered by Medicare Part D plans. One of the hardest categories to deal with on Medicare lately is weight loss drugs.

The Social Security Act spells out the rules for coverage of medications and excludes certain categories from coverage under Medicare, including “weight loss (even if used for a non-cosmetic purpose (i.e., morbid obesity).”

Medications that can be covered under Medicare Part D drug plans are approved by the FDA for medical reasons other than weight loss, such as diabetes or cardiovascular risk, which include Wegovy, Ozempic and Mounjarno. 

UPDATED: May 7, 2026

Medicare GLP-1 Bridge Program:  Get Some Weight Loss Drugs for $50 Copay

Source: CMS.gov | Last updated by CMS: May 6, 2026

Starting July 1, 2026, Medicare is running a temporary program that will help pay for certain weight-loss medications (the GLP-1 shots like Wegovy and Zepbound) for people who qualify. It runs through the end of 2027.

This program  operates outside the normal Part D benefit — meaning insurers don't carry the risk, and no Part D plan needs to "opt in" for their members to access it.

Key Dates

• Program begins: July 1, 2026
• Current planned end date: December 31, 2027

What Drugs Are Included?

As of now, CMS says the following medications may qualify when prescribed for weight loss/weight management:

• Wegovy®
• Zepbound® (KwikPen® formulation only)
• Foundayo®

CMS may update the list of eligible medications over time.

Who May Be Eligible?

To qualify for the Medicare GLP-1 Bridge, a person generally must:

• Be enrolled in Medicare Part D coverage
• Meet CMS prior authorization requirements
• Receive a prescription from a medical provider
• Meet the medical eligibility rules established by CMS

CMS says the program is intended for Medicare beneficiaries who meet obesity or overweight-related medical criteria.

Many Medicare beneficiaries with standalone Part D plans or Medicare Advantage drug plans may qualify, including some people with Extra Help and dual eligibility.

However, not every Medicare plan type qualifies for participation.

How Much Does It Cost?

CMS says eligible beneficiaries will generally pay:

The Medicare GLP-1 Bridge operates outside the standard Part D benefit structure. Because of this:

• The $50 copay does not count toward Part D TrOOP (True Out-of-Pocket costs)
• The drug costs do not count toward Part D deductible or catastrophic phases
• Extra Help/LIS subsidies generally do not reduce the Bridge copay

How Does the Program Work?

The Medicare GLP-1 Bridge is handled through a CMS central processor instead of through a person's Part D insurance plan.

That means:

• Doctors submit prior authorization requests to the CMS Bridge processor
• Pharmacies bill the Bridge program directly
• Part D plans are generally not involved in processing Bridge claims

Important Limitation

Some GLP-1 medications are already coverable under normal Medicare Part D rules for certain medically accepted uses, such as:

• Diabetes treatment
• Certain cardiovascular risk reduction indications
• Certain obstructive sleep apnea indications

If a medication is being prescribed for a use already covered under standard Part D rules, the prescription may need to go through the person's regular Part D plan instead of the Bridge program.

What Happens After 2027?

CMS intends for the Medicare GLP-1 Bridge to transition into a broader long-term program called the BALANCE Model.

Beneficiaries may eventually need to enroll in a participating Part D plan to continue receiving GLP-1 weight-loss coverage after the Bridge program ends.

Official Sources

•  CMS — Medicare GLP-1 Bridge 
•  CMS — BALANCE Model 
•  CMS Press Release — $50 Monthly Access to GLP-1 Medications 

Why doesn't a Medicare Part D plan cover weight loss meds for other FDA approved purposes?

 Medications approved by the FDA for purposes other than weight loss can be covered by Part D drug plans but that does not guarantee that these medications will be included in a drug plan’s formulary. (A formulary is a list of medication covered by a specific Part D plan.)

• According to Medicare rules, Medicare Part D plans must include "substantially all" drugs in six protected categories and classes. (No clear definition of what "substantially all" actually means.)
  • Anticonvulsants: Drugs to treat seizures and other seizure disorders. 
  • Antidepressants: Medications for depression and other mental health conditions. 
  • Antineoplastics: Cancer medications. 
  • Antipsychotics: Drugs for mental illnesses such as schizophrenia. 
  • Antiretrovirals: Medications used to treat HIV/AIDS. 
  • Immunosuppressants: Drugs to prevent organ transplant rejection.
    
    
• Outside of those six protected categories and classes, the rule is that Medicare Part D plans must cover at least two drugs in the most commonly prescribed categories and classes.
  • At least two drugs can mean just two drugs
  • The most commonly prescribed categories and classes does NOT mean all categories and classes.

Medicare Part D plans may not cover any medications in the categories and classes not considered to be the most commonly prescribed.

GLP-1 generics, Zepbound, Saxenda and other medications simply for weight loss are not covered by Medicare and any Part D drug plan.

Check these links for additional information. 

• Medicare Part D Coverage Of Wegovy: Three Stumbling Blocks—https://www.forbes.com/sites/dianeomdahl/2024/08/06/medicare-part-d-coverage-of-wegovy-three-stumbling-blocks/
• Proposed Coverage of Anti-Obesity Drugs—https://www.kff.org/policy-watch/proposed-coverage-of-anti-obesity-drugs-in-medicare-and-medicaid-would-expand-access-to-millions-of-people-with-obesity/

Alternative Methods for Obtaining Weight Loss Drugs

Formulary Exceptions For Drugs Not Covered by Part D Plans

In the middle of a plan year, if you need a medication that your drug plan does not cover, your physician can request a Formulary Exception.

This would allow you to:

• Obtain a Part D drug that is not included on a plan sponsor’s formulary, *OR*
• Obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit).

The physician’s supporting statement must indicate that the non-formulary drug is necessary for treating a condition because all covered Part D drugs would not be as effective or would have adverse effects.

If the plan sponsor denies the request, there is an appeal process. 

Check these links for more information:

• Medicare prescription drug coverage appeals — https://medicare-links.com/formulary-exception
• Coverage exceptions, CMS — https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions