Why Aren’t My Weight Loss Drugs Covered by Insurance?
Lots of folks are concerned about access to GLP1 medications like Ozempic, Monjouro and Zepbound. GLP1s are back in the news because of recent rollbacks on prescription price control in response to an announcement from the Center for Medicare and Medicaid Services (CMS).
GLP-1 medications are appetite suppressants that cause people to feel full. GLP-1 helps regulate blood sugar levels by stimulating insulin secretion and slowing down digestion. Semaglutide GLP1 medications are administered through once-weekly injections under the skin, starting with smaller doses that increase gradually over time with doctor supervision.
These medications are approved by the FDA for the treatment of diabetes, however, some doctors have begun prescribing them off-label to manage obesity due to their effectiveness for weight loss. Only Wegovy, a higher dose Semaglutide, is approved by the FDA to treat obesity, and at around $1000 a month, getting hold of these coveted weight loss medications is incredibly expensive.
Since obesity is now widely agreed to be a disease, some have argued that the use of these medications for weight loss should be covered by insurance. The Biden administration had proposed in 2024 to expand Medicare and Medicaid coverage of these drugs to treat obesity, a regulation that would enable many more Americans to afford these medications for weight loss.
This policy would have gone into effect in 2026 if the Trump administration had backed the change; however, CMS recently announced that it has decided against covering these medications for weight loss under Medicare and Medicaid prescription drug coverage.
The individual and small group markets already do not cover weight loss medications, but with this recent rollback from the Trump administration, the Medicare market will not cover them either.
If this regulation had been adopted, the reduced drug cost and the $2,000 out-of-pocket limit for Part D medication would have given lower-income and elderly folks access to the same weight loss potential that celebrities and wealthy folks have been paying out of pocket for. Patients on Medicare using GLP1s to treat their diabetes are now also seeing higher costs for their prescriptions, due to the Trump administration repealing Biden’s executive order for capped drug copays under Medicare prescription plans.
While CMS has not given a reason for its decision not to pursue covering these drugs for weight loss, for many folks, this feels like another blow amid many rapid changes from CMS. Those who hope to see insurance coverage for weight loss drugs will have to continue to contend with the expensive price tag for the foreseeable future.
