Will Medicare Ever Cover Zepbound?
Zepbound, a weight-loss drug, has helped many people manage obesity. Medicare currently doesn’t cover it for weight loss, leaving patients wondering about future possibilities.
This article explores whether Medicare will ever cover Zepbound, recent policy changes, and what it means for patients.
What Is Zepbound?
Zepbound is an FDA-approved medication for weight management. Its active ingredient, tirzepatide, reduces appetite and supports weight loss. It’s prescribed for adults with obesity or weight-related health conditions.
The drug is available as pre-filled pens or vials. It’s effective but costly, with a list price over $1,000 monthly. This makes Medicare coverage a critical issue for many.
Current Medicare Coverage for Zepbound
Medicare Part D and Part C plans don’t cover Zepbound for weight loss. A 2003 law prohibits Medicare from covering weight-loss drugs. This stems from viewing obesity as a lifestyle issue, not a chronic condition.
However, Zepbound is covered for obstructive sleep apnea (OSA), approved by the FDA in December 2024. Coverage applies only when prescribed for OSA, not weight loss.
Why Doesn’t Medicare Cover Weight-Loss Drugs?
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 bans coverage of weight-loss medications. Early weight-loss drugs had safety concerns, influencing this decision. Obesity was seen as manageable through diet and exercise.
This law remains in place, limiting access to drugs like Zepbound. Many patients pay out of pocket, facing high costs. Policy changes are needed for broader coverage.
Recent Updates on Zepbound and Medicare
In November 2024, the Centers for Medicare & Medicaid Services (CMS) proposed reinterpreting the weight-loss drug ban. This could allow Medicare to cover Zepbound for obesity starting in 2026. The proposal recognizes obesity as a chronic disease.
The Biden administration supports this change, but it requires finalization. The incoming Trump administration will decide its fate. If approved, coverage could expand significantly.
Zepbound’s Coverage for Other Conditions
Medicare Part D covers Zepbound for OSA, a sleep disorder affecting millions. This followed FDA approval in December 2024, making Zepbound the first drug for moderate to severe OSA. Coverage is limited to this use.
Mounjaro, another tirzepatide drug, is covered for type 2 diabetes. This shows Medicare covers tirzepatide for non-weight-loss purposes. Similar approvals could open doors for Zepbound.
Proposed Policy Changes for 2026
The CMS proposal aims to expand Medicare coverage for weight-loss drugs like Zepbound. It would cover them for obesity, not just secondary conditions like OSA. This could benefit 3.4 million Medicare users.
If finalized, the rule would also require Medicaid to cover these drugs. The change hinges on the Trump administration’s approval. Public comment ends January 27, 2025.
Challenges to Expanding Coverage
Expanding Medicare coverage for Zepbound faces hurdles. The high cost, over $1,000 monthly, could strain Medicare’s budget. Estimates suggest $35 billion in added costs over a decade.
Critics, like Senator Bernie Sanders, warn of rising premiums. Supply shortages could worsen with increased demand. The Trump administration’s stance, including RFK Jr.’s skepticism, adds uncertainty.
Table: Zepbound Coverage by Condition
| Condition | Medicare Coverage | Notes |
|---|---|---|
| Weight Loss | Not Covered | Prohibited by 2003 law |
| Obstructive Sleep Apnea | Covered (Part D) | FDA-approved in December 2024 |
| Type 2 Diabetes (Mounjaro) | Covered (Part D) | Same active ingredient as Zepbound |
Note: Coverage is as of February 2025 and subject to change.
Legislative Efforts to Change Coverage
The Treat and Reduce Obesity Act, introduced since 2013, seeks to lift the weight-loss drug ban. In June 2024, the House Ways and Means Committee advanced a scaled-back version. It would cover drugs for current Medicare enrollees already using them.
The bill hasn’t passed the full House yet. It faces resistance due to cost concerns. Passage could set a precedent for Zepbound coverage.
How Zepbound’s OSA Approval Helps
Zepbound’s OSA approval is a step toward broader coverage. Medicare Part D plans cover it for OSA, requiring prior authorization to confirm medical necessity. This shows flexibility in covering weight-loss drugs for secondary uses.
Future FDA approvals for conditions like heart disease could expand coverage. Drugmakers are studying tirzepatide for such uses. Success would strengthen the case for Zepbound.
What Would Coverage Mean for Patients?
If Medicare covers Zepbound for weight loss, millions could access it. About 40% of Americans are obese, and many are Medicare beneficiaries. Coverage would reduce out-of-pocket costs, currently $1,060 monthly.
Patients would need prescriptions meeting FDA criteria, like a BMI of 30 or higher. Prior authorization might apply, ensuring proper use. Access would improve significantly.
Alternatives for Uninsured Patients
Without Medicare coverage, patients pay full price for Zepbound. Lilly Direct offers vials at $349 for 2.5 mg or $499 for higher doses with the Self Pay Journey Program. This is cheaper than pens.
Discounts from GoodRx or SingleCare can lower pen costs to around $1,025. Compounded tirzepatide, costing $250–$400, is riskier and lacks FDA approval. Discuss options with your doctor.
Why Coverage Matters
Obesity is a chronic disease linked to heart disease, diabetes, and more. Zepbound helps manage it, improving health outcomes. Medicare coverage would make it affordable for seniors and disabled patients.
Lack of coverage forces many to skip treatment or face financial strain. Policy changes could address this gap. Advocacy for obesity as a medical condition is growing.
The Role of the Trump Administration
The proposed 2026 rule depends on the Trump administration’s decision. RFK Jr., Trump’s pick for HHS secretary, prefers dietary changes over weight-loss drugs. This could halt the proposal.
However, public demand and medical support may push for coverage. Dr. Mehmet Oz, CMS nominee, has praised these drugs. The outcome remains uncertain.
How to Prepare for Potential Coverage
Patients hoping for Zepbound coverage should stay informed. Check your Medicare Part D plan’s formulary for updates. Contact your insurer to confirm coverage for OSA or future indications.
Work with your doctor to document medical necessity, like OSA or obesity-related conditions. Be ready for prior authorization requirements. Stay updated on CMS announcements.
Other Ways Medicare Supports Weight Loss
Medicare covers obesity-related services, like bariatric surgery and behavioral therapy. These are alternatives for patients ineligible for Zepbound. Some Medicare Advantage plans offer fitness programs.
Screenings for diabetes and heart disease are also covered. These services help manage weight indirectly. Check your plan for details on available benefits.
Summary
Will Medicare ever cover Zepbound for weight loss? Current laws prevent it, but a 2026 CMS proposal could change this, recognizing obesity as a chronic disease. Zepbound is already covered for OSA, showing potential for broader coverage. Legislative efforts and FDA approvals for new uses could help. High costs and political uncertainty pose challenges, but coverage would benefit millions. Patients can use Lilly Direct, coupons, or explore compounded options while awaiting policy changes.
FAQ
Will Medicare ever cover Zepbound for weight loss?
A 2026 CMS proposal could allow coverage for obesity, but it needs Trump administration approval. Currently, Medicare doesn’t cover Zepbound for weight loss. Check for updates after January 2025.
Why is Zepbound covered for sleep apnea but not weight loss?
Medicare covers Zepbound for OSA due to its FDA approval in December 2024. A 2003 law bans coverage for weight-loss drugs. Only secondary uses are covered.
How much does Zepbound cost without Medicare coverage?
Zepbound pens cost $1,000–$1,300 monthly. Lilly Direct vials are $349–$699, with discounts via the Self Pay Journey Program. Coupons can lower pen costs.
What is the Treat and Reduce Obesity Act?
It’s a bill to lift Medicare’s weight-loss drug ban. A scaled-back version passed committee in 2024 but awaits full House approval. It could enable Zepbound coverage.
Can I appeal if Medicare denies Zepbound coverage?
Yes, if denied for OSA, review the denial notice and gather evidence like sleep studies. Follow your plan’s appeal process. Consult your doctor for support.