Older Americans previously could only access GLP-1 coverage for diabetes or cardiovascular disease through Medicare. See if you qualify now.
Some Medicare patients will soon have access to GLP-1 drugs for weight loss through a prescription-drug plan. Here's what to know.
Medicare will begin covering GLP-1 drugs specifically for weight loss for the first time starting Wednesday, July 1.
Novo Nordisk's (NVO) Wegovy pill or injection or Eli Lilly's $(LLY)$ Foundayo pill or Zepbound KwikPen will soon be available under Medicare Part D plans, which offer add-on coverage for prescription drugs, for patients who meet specific qualifications.
The weight-loss drugs come with a $50 monthly copay that doesn't count toward the plan's deductible or out-of-pocket limit. Without insurance coverage, the cost of obesity drugs ranges from $149 to $1,060 a month, depending on dosage and whether it's a pill or injectable.
Until this week, Medicare only covered GLP-1 drugs for conditions like Type 2 diabetes, sleep apnea, and stroke or heart-attack risk.
About 3 million people who meet Medicare's criteria are expected to qualify for the new program. Here are the specific eligibility requirements - and complexities of the new program to consider - for those looking to start GLP-1 treatment for obesity.
Eligibility requirements to access GLP-1s for weight loss under Medicare
-- Enrollment in a Medicare Part D drug-coverage plan. This includes a standalone Medicare drug plan, a Medicare Advantage coordinated care plan with drug coverage (including Health Maintenance Organizations, HMO Point-of-Service plans and local and regional Preferred Provider Organization, or PPO, plans), a Special Needs Plan (SNP), an employer/union group waiver plan (EGWP) and the Limited Income Newly Eligible Transition (LI NET) program.
-- A body mass index of at least 35, or a BMI between 27 and 34.99 with a qualifying condition. Qualifying patients with BMIs between 30 and 34.99 must also have diastolic heart failure, hypertension, chronic kidney disease at stage 3a or higher, a previous heart attack or stroke, prediabetes or blocked arteries in your legs or arms with symptoms. Those with BMIs between 27 and 29.99 must also have prediabetes, a previous heart attack or stroke, or blocked arteries in your legs or arms with symptoms.
-- A prescription from a doctor or healthcare provider.
-- You must not already get other GLP-1 drugs through Medicare Part D.
-- You must not have Type 2 diabetes, moderate to severe sleep apnea or fatty-liver disease. However, your Part D plan might still cover GLP-1s for these conditions.
Other important considerations
The pilot program is set to expire at the end of 2027
The temporary nature of the program is concerning to physicians, as GLP-1s are long-term maintenance medications.
If a patient stops treatment because they can no longer afford it, "not only will weight come back, comorbidities will come back, and we know from lifestyle studies ... when you gain it back, you're gaining more fat than muscle," John Batsis, a geriatrician and obesity specialist at the University of North Carolina School of Medicine, told MarketWatch.
You must complete the prior-authorization process
This is an approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered.
The $50 copay doesn't count toward out-of-pocket costs
The copay is not included in Part D coverage, which means it doesn't count toward the plan's deductible or out-of-pocket limit, it won't appear on your Explanation of Benefits or Medicare Summary Notice, it can't be lowered by programs like Extra Help and it can't be spread across multiple months using the Medicare Prescription Payment Plan.
Still unsure? Here's additional MarketWatch coverage on GLP-1s and Medicare to help inform your decision
-- Older Americans will soon have Medicare access to GLP-1s for weight loss for the first time. Here's what they need to know.
-- Here's how much weight-loss drugs Wegovy, Zepbound and Foundayo cost - and how to pick the best GLP-1 for you
-- A new wave of weight-loss therapies aims to be better than today's GLP-1s
-- The Wegovy pill is still dominating the GLP-1 pill market
-- Lilly's GLP-1 medications will soon be covered by CVS, potentially opening access for millions of Americans
-- A new bill would cap Medicare enrollees' annual expenses at $5,000 - and could cost the government 'tens of billions'
-- Social Security's woes are well known, but Medicare is also facing a fiscal crisis - in just 7 years
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June 30, 2026 14:44 ET (18:44 GMT)
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