As a major 'side effect,' they also experience significant weight loss, improved blood pressure, and better cholesterol levels. At the time, the available medications were primarily stimulants with significant side effects and a reputation for being 'vanity' drugs. What was once covered under your employer-sponsored plan might suddenly be off the table. You’re 64, on the cusp of enrolling in Medicare, and you’re also seriously considering or are already using a modern weight loss medication like Semaglutide or Tirzepatide. As a result, they don’t plan financially for such expenses throughout their working years. The above tips can help you avoid or successfully manage a chronic condition. The danger of hypertension is not only that you can have it for years and not know it, but it can cause other serious health conditions, like stroke and heart attacks. NCOA is pressing to define quality obesity care as a universal right. Chances of having diabetes increases after age 45. When this doesn’t happen, you get high blood sugar, which can lead to complications such as kidney disease, heart disease, or blindness. For many who are facing the Medicare coverage cliff, this model isn't just a convenience; it's a lifeline. Now, you might be thinking about Medicare Advantage plans. If your current plan covers a drug like Wegovy or Zepbound, this is your moment to work with your healthcare provider to begin treatment. The medication is no longer just for weight loss; it’s for protecting cardiovascular health. However, a patient without type 2 diabetes who is prescribed the chemically identical drug (Wegovy or Zepbound) for chronic weight management will likely face a denial from their Part D plan. Patients must have documented cardiovascular disease and meet specific BMI criteria to qualify for coverage under this indication. Medicare Part D plans typically cover these drugs on their formularies, though prior authorization requirements and step therapy protocols may apply depending on the specific plan. However, this exclusion doesn’t apply when weight loss medications have FDA-approved indications for other medical conditions. Medicare’s approach to weight loss medications creates confusion for millions of beneficiaries seeking help with weight management. It's essential to check with your specific insurance provider to see what is covered by your specific plan. Ozempic, Wegovy, and other weight loss drugs only recently became popular. It is often used for people who are overweight and also have diabetes, high blood pressure, high cholesterol, or heart disease. While these drugs are relatively new, there are several FDA-approved weight loss drugs on the market. “We need Medicare to cover these drugs,” said Shauna Matilda Assadzandi, a geriatrician at the University of Pittsburgh who cares for Morris. Will they reduce rates of disability and improve people’s ability to move and manage daily tasks? (Patients need to remain on the drugs permanently or risk regaining the weight they’ve lost.) In other words, the injections, which can cost well over $1,000 a month out of pocket, will not be covered for enrollees only seeking to lose weight. “What we did is we looked at the long-term health consequences of treating obesity in the Medicare population,” said the study’s co-author, Darius Lakdawalla, the director of research at the center. When deciding what medication to prescribe, Shauna Levy, M.D., medical director of the Tulane Bariatric and Weight Loss Center in New Orleans, says insurance is her number one limiting factor. Though some GLP-1s have been FDA-approved for weight loss, others have not. Drugs prescribed for weight gain, cosmetic purposes, fertility, hair growth and treatment of sexual or erectile dysfunction also aren’t allowed to be covered. Administration officials expect that percentage to rise to 10 percent, about 7 million people, with the GLP-1 discounts. The FDA approved the first GLP-1 pill for weight loss earlier this week, and the oral form of Wegovy is expected in pharmacies in early January 2026. You can get your Medicare coverage through Original Medicare or through a Medicare Advantage plan. The tirzepatide solution for injection vial remains in shortage and is expected to stay that way until August next year, with demand for weight loss drugs showing no signs of slowing down. If you are interested in prescription drug coverage, you would need to add an additional Part D plan or choose a Medicare Advantage Prescription Drug plan. Afterwards, you may work online, over the phone, or in person with a trusted licensed insurance agent or broker to complete enrollment in a Medicare Advantage plan. Medicare for Disabled Under 65 Understanding how Medicare eligibility age works will help you plan your healthcare coverage with confidence. Medicare Advantage plans require you to seek care within its network of providers for coverage. For example, if you are still working and have employer-sponsored health insurance, you may opt to keep that as your health coverage instead of enrolling in Medicare. Knowing your Medicare eligibility age and year will help you prepare for your enrollment period, avoid any late enrollment penalties, and ensure you have the healthcare coverage you need when you need it. The Top 10 Most Common Chronic Conditions in Older Adults Participation also depends on manufacturers, states, and plans. Cms has said a bridge demonstration is planned for july 2026, with the balance model in medicaid as early as may 2026 and in medicare part d in january 2027. Exact rules can change as negotiations finalize, but reporting around the program and related pricing agreements suggests the target population is expected to be older adults with obesity or overweight plus serious metabolic or cardiovascular risk. With the change in government in 2025 and the Trump administration now in power, it is unknown if the Treat and Reduce Obesity Act will be moved forward and written into health policy. Medicare Part D will cover Ozempic when it’s used to manage diabetes. It’s important to note, not everything on kffhealthnews.org is available for republishing. You must credit us as the original publisher, with a hyperlink to our kffhealthnews.org site. We encourage organizations to republish our content, free of charge. Tips to Be Prepared and Banish Fear of Hospitals While Living with Chronic Illness Medicare’s complex rules around weight loss medications leave millions of beneficiaries confused about what’s actually covered. Many people are surprised to find that drugs covered by their old plan are not covered by their new one. You must review the formulary of your new Medicare Part D or Medicare Advantage plan to see if your medications are covered. About 16% of older have heart disease—a condition that occurs when the heart cannot adequately supply blood and oxygen to all of the organs in the body. 15% of older adults have depression—a treatable medical condition that is not a normal part of aging. With these kinds of odds, you might wonder if there is anything you can do to prevent the onset of a chronic medical condition, or make managing an existing one easier. Age, family genetics, and gender make it nearly impossible for older adults to avoid becoming a chronic disease statistic. If you are considering a Medicare Supplement, Medicare Advantage or Prescription Drug Plan, let us help you. Unfortunately, a lack of knowledge about Medicare doesn’t stop people from enrolling once eligible. If you feel your doctor is not listening to your concerns, or that they don’t take obesity seriously as a chronic disease, it may be time to find a new provider. In a clinical trial, subjects who received a weekly injection of semaglutide lost an average of 15% of their total starting body weight.2 This weight loss medication also reduces feelings of hunger. They may also prescribe it if you’ve been diagnosed with a condition related to your weight—such as type 2 diabetes, high blood pressure, heart disease, or sleep apnea. That number doesn't include the 7 million who may already qualify because they have diabetes plus obesity. As many as 3.6 million people are most likely to qualify. You are being redirected to an another page. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin. You’ll pay a premium, and a copay or coinsurance. If you choose Medicare, you’ll need a Part D drug plan. But if you’re under 65, it can be hard to find an affordable Medigap plan. Plant-based diets: the health trend taking the nation by storm Understanding your current policy terms, including coverage limits for cancer care, helps you make informed decisions.The law itself, the very foundation of the Part D program, explicitly forbids coverage for medications used for the sole purpose of weight loss.During the Biden administration, it was proposed that Medicare prescription drug benefits cover weight loss drugs for obesity treatment.Medicare coverage for people under 65 with disabilities is tied to Social Security Disability Insurance (SSDI) benefits.I wasn’t hungry at all and I lost weight like mad,” said Morris, who has shed 40 pounds.And obesity, which impacts about 40% of adults 65 and older,1 can increase your risk for conditions like heart disease, type 2 diabetes, and some cancers.2Some research shows offering weight loss drugs would assure Medicare’s impending bankruptcy.More commonly known as Medigap, this insurance can help pay original Medicare’s deductibles, copayments and other out-of-pocket costs. This allowed them to calculate cardiovascular risk scores for every Medicare-enrolled person with a body mass index of 27 kg/m2 and above who didn't already have a history of heart attack, stroke, coronary artery disease or angina. "However, the other 6 of the 7 would not, and most of them also have an elevated cardiovascular risk based on their overall health status." But they could potentially take more of a preventive approach -- like they do with many medications that reduce the risk that someone will have a heart attack or a stroke. They can also lower your risk of heart disease, diabetes, and other weight-related health conditions. Combined with healthy eating and exercise, these medications can help you lose weight, even after 60, when losing weight is more challenging. Before late 2024, Medicare had not been covering Zepbound because the FDA has approved it for weight loss only. Some plans require you to try other medications first. Even though the Medicare Plan Finder may identify Ozempic as covered, that doesn’t mean you will qualify for coverage. Even if you can’t buy a Medigap policy before age 65, you might consider enrolling in a Medicare Advantage plan, an alternative to original Medicare. Our agents consider the coverage you need and make the best recommendation based on your situation. While some states require companies to offer at least one Medigap plan to people under age 65, others do not. A Special Needs Plan fits the healthcare needs of the people in the policy. A Vanderbilt University analysis this year put an annual price of about $26 billion on anti-obesity drugs for Medicare if just 10% of the system’s enrollees were prescribed the medication. Last year, about 40% of the nearly 66 million people enrolled in Medicare had obesity. Medicare will cover obesity screening and behavioral treatment if a person has body mass index over 30. Private insurers often do not cover the medications or place strict restrictions on who can access them. But research shows the initial price tag of covering those drugs is so steep it could drain Medicare’s already shaky bank account. You can sign up when you first become eligible for Medicare, and every fall during Medicare's open enrollment period. Once you turn 65 you will again have an open enrollment period for a Medicare supplement or Medicare Advantage plan. Learn more about chronic disease self-management, a low-cost program that helps people with chronic diseases learn how to manage and improve their health. Medicare Advantage plans are offered by private insurance companies. This story, originally published Sept. 13, 2023, was updated to reflect the FDA’s recent approval of a pill form of Wegovy and CMS’s two-step plan to lower prices for Medicare Part D enrollees. You must itemize your deductions, and qualified medical expenses are deductible only if they’re more than 7.5 percent of your adjusted gross income. Tax-deductible medical expense. For example, if you turn 65 on July 4, 2026, the enrollment window opens on April 1.If you’re living with obesity and have tried diet and exercise with limited success, weight loss medications could give you an added boost.You’ll pay a premium, and a copay or coinsurance.Because private and employer-sponsored plans often have vastly different—and frequently more generous—rules for covering new-generation weight loss medications, often called GLP-1 agonists.On average, the trendy GLP-1 medications have helped people lose 12 percent of their total weight.High-cost specialty medications often fall on higher formulary tiers with coinsurance rates between 25% and 33%, depending on the plan’s deductible structure.“People call their insurance and ask if Ozempic is covered, and they say it is, but if you don’t have diabetes, it’s not covered.” Dr Deed said he is still seeing patients everyday expressing interest in weight loss medications, and that a high price may not be a deterrent for some. It is eligible to adults with an initial body mass index (BMI) of ≥30 kg/m2 or ≥27 kg/m2 in the presence of at least one weight-related comorbid condition, such as hypertension, dyslipidaemia, obstructive sleep apnoea, cardiovascular disease, pre-diabetes or type 2 diabetes. But a Therapeutic Goods Administration (TGA) decision on Tuesday means the medication is now indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management, including weight loss and weight maintenance. The newer injectable drugs have a high out-of-pocket cost. As a person with obesity, you should know and understand all the treatment options available to you. Learning to be your own advocate can help you get the high-quality obesity care you need. If you need health insurance while you’re waiting for Medicare to kick in, you can get it through a former employer, your spouse’s employer, or the marketplace. Medicare was established in 1965, as a program to provide health insurance for older adults. It’s common knowledge that Medicare is available for people 65 and over, but you may be surprised to learn that about 10% of Medicare beneficiaries, or nearly 7 million people, are under age 65. About 10.5 percent of Medicare beneficiaries are younger than 65 and receive Medicare because of a disability or specific medical condition. It starts at age 65 for most. Which path you take will determine how you get your medical care — and how much it costs If you already have a Medigap policy but are paying high rates, this is when you can switch to another policy that has lower rates. Others mandate the inverse, saying only people with kidney failure must be offered Medigap. And because the program is a test, coverage will end in December 2031 unless the program is extended. The proposed pilot program would test coverage models in selected states or regions, evaluating both clinical outcomes and cost-effectiveness. Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) can be used to pay for qualifying weight loss medications with pre-tax dollars. Coverage varies by plan type, so it’s important to review your Medicare Advantage plan options to see which formularies include these drugs. The prior authorization process requires doctors to submit medical documentation proving the medication is medically necessary for the approved indication, not weight loss. “And that’s been the basis for coverage all this time,” McClellan said. Rep. Brad Wenstrup, R-Ohio, introduced legislation with Rep. Raul Ruiz, D-Calif., this year that would allow Medicare to cover the now-forbidden anti-obesity drugs, therapy, nutritionists and dieticians. Medicaid, the state and federal partnership program for low-income people, does cover the drugs in some areas, but access is fragmented. You pay separate premiums based on the Part D plan you choose. Most people receive Part A free because they or their spouses have worked and paid Medicare taxes for at least 40 calendar quarters. You experience permanent kidney failure requiring regular dialysis or a kidney transplant. You have Lou Gehrig’s disease, also known as amyotrophic lateral sclerosis (ALS), which qualifies you immediately. How do I get Medicare coverage for Wegovy? People can lose as much as 15% to 25% of their body weight on the drugs, which imitate the hormones that regulate appetites by communicating fullness between the gut and brain when people eat. "In practice, the way we treat both groups of people with elevated risk scores is not dissimilar -- we're making medical management decisions and lifestyle recommendations to prevent a future incident," Chaitoff explained. Chaitoff, who provides primary care to veterans at VAAAHS, notes that Medicare Part D and Medicare Advantage plans could opt to set conditions to determine which high-risk patients could qualify for treatment with semaglutide. Medicare coverage of semaglutide -- but for whom? Individual qualifies for both Medicare and Medicaid for either partial or full coverage. Two-thirds of companies with 20,000 or more workers covered them. Some employer insurance. You can pay out-of-pocket, taking advantage of the lower prices expected to be available on drug manufacturers’ websites linked to from TrumpRx. Twenty-four percent of older adults have diabetes—a disease that occurs when your body is resistant to, or doesn’t produce enough, insulin. Your health provider can give you recommendations on what screenings are right for you. Routine screenings are important for catching cancer in its earlier, more treatable stages. Some Medicare Advantage plans, called Chronic Condition Special Needs Plans (C-SNPs), are available to those with specific chronic conditions, such as cancer, heart failure, and severe mental illness, says Huberty. “However, states can expand the Medigap enrollment protections to include people under 65 with disabilities.” For example, in New York, Medigap is available to anybody on Medicare, regardless of their age, Whicheloe says. However, this coverage may be trickier to get, says Whicheloe. Medication alone won’t be sufficient; we will still need to address behaviors,” said Sukhpreet Singh, system medical director at Henry Ford’s weight management program. “My concern is, once we put patients on these obesity drugs, are we supporting lifestyle changes that will maintain their health? I wasn’t hungry at all and I lost weight like mad,” said Morris, who has shed 40 pounds. (Ozempic was approved for diabetes in 2017.) Several other drugs are in development. Managing her weight was a losing battle until Morris’ doctor prescribed a Type 2 diabetes medication, Ozempic, four months ago. After her weight began climbing in high school, she spent years losing 50 or 100 pounds then gaining it back. Obesity doctor Angela Fitch says that the move to cover it even for a limited subset of patients is still significant. Children 19 years of age or older who don’t qualify for Medicare may qualify for Medicaid. If your child is over the age of 20, they qualify for Medicare after receiving SSDI benefits for at least 24 months. Many people on Social Security Disability qualify for Extra Help with Part D costs. All weight loss medications—both newer and older versions—come with the risk of unpleasant side effects. However, when combined with healthy lifestyle changes, these drugs could help you treat your condition, improve your health, and lose more weight in the long run. Understanding the pros and cons of weight loss medications can help you make an informed decision about taking them. In earlier trials, patients taking orforglipron achieved an average 14.7% weight loss. In a study, the average weight loss of participants taking Zepbound ranged from 15% to 20.9%. These plans are only available to people who meet specific criteria, such as having a particular chronic and disabling health condition or being eligible for both Medicare and Medicaid. Medicare Advantage plans combine Medicare coverage with additional benefits to become your primary coverage. “Medicare Part D, or prescription drug coverage, is available to people under 65 who are eligible for Medicare,” says Whicheloe. Because Medicare doesn’t cover weight loss medications and they can cost more than $10,000 a year, seniors’ ability to get the new drugs is restricted. Both types of plans must follow the federal rule excluding drugs for weight loss.It also allows the government’s Medicare Plan Finder to include the information as potential enrollees shop for standalone Part D prescription plans and Medicare Advantage coverage.Many of these plans have recognized obesity as a chronic disease and cover the medications prescribed to treat it.Still, weight loss alone should not be recommended to older adults, because it entails the loss of muscle mass as well as fat, experts agree.This is a set of eight patient-centered principles to ensure all Americans with obesity have access to the high-quality treatment options they need and deserve.Wondering ‘can omeprazole cause weight loss’?You can sign up when you first become eligible for Medicare, and every fall during Medicare's open enrollment period. Once you turn 65 you will again have an open enrollment period for a Medicare supplement or Medicare Advantage plan.Safety problems in the 1990s with the anti-obesity treatment known as fen-phen, which had to be withdrawn from the market, were also fresh in their minds.In 2025, nearly all health plans covered GLP-1s for diabetes and 49 percent of plans from companies with 500 or more employees for weight loss, according to Mercer’s National Survey of Employer-Sponsored Health Plans. Retiree health insurance. “People call their insurance and ask if Ozempic is covered, and they say it is, but if you don’t have diabetes, it’s not covered.” “You can get your doctor to write you a prescription for off-label use as a weight loss drug. Discover Evening Wellness: Join Penn State Extension’s Webinars on Healthy Habits AARP’s Medicare experts share tips and updates to help manage your health care costs. Licensed insurance agent services are provided by HealthCompare Insurance Services, Inc., an Allstate company. These programs typically require income verification and may offer free or reduced-price medications for eligible patients. What are state rules for Medigap under age 65? It also allows the government’s Medicare Plan Finder to include the information as potential enrollees shop for standalone Part D prescription plans and Medicare Advantage coverage. This medical indication enables potential Medicare coverage when the medication is prescribed to address sleep apnea rather than weight management. This indication allows Medicare Part D plans to cover Wegovy when prescribed specifically for cardiovascular protection rather than weight loss. No, just like Wegovy, Zepbound is not covered by Medicare Part D plans when prescribed solely for chronic weight management. For those diagnosed with ALS (Lou Gehrig’s disease), Medicare is available immediately upon receiving SSDI approval. Click the button below to go to KFF’s donation page which will provide more information and FAQs. We appreciate all forms of engagement from our readers and listeners, and welcome your support. Sick of Fighting Insurers, Hospitals Offer Their Own Medicare Advantage Plans The 17-year-old law may provide a blueprint for expanding coverage of the new drugs, which mirror the results of bariatric surgery in some cases, McClellan said. Notably, Medicare does cover certain surgical procedures to treat medical complications of obesity in people with a body mass index of 35 and at least one related condition. As obesity rates rise among older adults, some lawmakers say the United States cannot afford to keep a decades-old law that prohibits Medicare from paying for new weight loss drugs, including Wegovy and Zepbound. "Ultimately we need to ask ourselves, what level of evidence are we requiring for coverage of certain drugs, compared with the level of evidence that we require for coverage of other treatments," Chaitoff said. “A blanket prohibition for use of anti-obesity medication is an antiquated way of thinking and does not recognize obesity as a disease and is perpetuating health disparities,” Kraftson said. Lakdawalla said it’s nearly impossible to put a cost on covering the drugs because no one knows how many people will end up taking them or what the drugs will be priced at. Some research shows offering weight loss drugs would assure Medicare’s impending bankruptcy. The American Kidney Fund estimates that Part B coinsurance can cost dialysis patients $10,000 or more out of pocket each year. Thirty-four states now require Medigap insurers to offer at least one policy to Medicare recipients younger than 65. People 65 and older can get any Medigap policy available in their area at the best rates if they buy at certain times — such as within six months after signing up for Medicare Part B. We do not offer every plan available in your area. The purpose of this website is the solicitation of insurance. Yet, many people assume that Medicare will take care of at least a portion of these costs. Consequently, their selection of plan options may be smaller. Premiums, deductibles, and coinsurance can add up over a short time on Original Medicare. It’s best to take advantage of your Initial Enrollment Period to do so. One big misconception is that every American automatically gets Medicare at age 65. Even with a very high BMI and related health issues, the exclusion still applies.Enrollment depends on the plan’s contract renewal.Not all plans offer all of these benefits.Administration officials expect that percentage to rise to 10 percent, about 7 million people, with the GLP-1 discounts.“If you are under 65 and qualify for original Medicare because of a disability, you are also eligible for Medicare Advantage plans,” says Huberty.It is eligible to adults with an initial body mass index (BMI) of ≥30 kg/m2 or ≥27 kg/m2 in the presence of at least one weight-related comorbid condition, such as hypertension, dyslipidaemia, obstructive sleep apnoea, cardiovascular disease, pre-diabetes or type 2 diabetes.For many who are facing the Medicare coverage cliff, this model isn't just a convenience; it's a lifeline.This isn't about gaming the system; it's about strategic, proactive management of your own health within the rules that are currently available to you.Evidence showed that the surgery reduced the risks of death and serious illness from conditions related to obesity. Several states make at least one Medicare supplement (also known as \u201cMedigap\u201d) policy available for those under age 65. Several states make at least one Medicare supplement (also known as \u201cMediGap\u201d) policy available for those under age 65. You can sign up when you first become eligible for Medicare, and every fall during Medicare’s open enrollment period. Several states make at least one Medicare supplement (also known as “MediGap”) policy available for those under age 65. One study showed that some people taking prescription weight loss medications were able to achieve and maintain a loss of 10% or more of their starting body weight.4 Not all people with a high BMI should take weight loss medications. They’re meant for people who struggle with health problems due to being overweight or having obesity. If you’re living with obesity and have tried diet and exercise with limited success, weight loss medications could give you an added boost. Sorting through Medicare’s many coverage options can be confusing—and choosing the wrong plan could cost you much more in the long run. Others mandate the inverse, saying only people with kidney failure must be offered Medigap.About 16% of older have heart disease—a condition that occurs when the heart cannot adequately supply blood and oxygen to all of the organs in the body.Medicare Part D will cover Ozempic when it’s used to manage diabetes.Once you turn 65 you will again have an open enrollment period for a Medicare supplement or Medicare Advantage plan.In some states, Medigap plans are only available to certain types of beneficiaries, such as people with end-stage renal disease.Many seniors use these medications successfully, but safety depends on individual health status, kidney function, other medications, and close monitoring—especially to prevent dehydration and muscle loss.Obesity increases the risk of heart disease, stroke, type 2 diabetes and other conditions.If you have any questions, Contact Us, and one of our friendly Personal Benefits Manager will be happy to assist. Doctors have been prescribing GLP-1s for weight loss because studies have found that losing 5 percent to 10 percent of your weight can have positive effects on your health. In addition to helping with weight loss, GLP-1s, or glucagon-like peptide-1 receptor agonists, have been found to improve heart and liver health and treat sleep apnea in overweight adults. “Coverage and pricing changes will phase in during 2026 with cash prices for TrumpRx purchases as early as January,” says Michael Baker, director of health care policy at the American Action Forum. By July, CMS will launch its own short-term program to allow eligible Medicare Part D prescription plan beneficiaries to pay $50 a month for GLP-1 medications for the rest of the year. They are sponsored by Medicare, which pays private companies for providing the coverage, but you are limited to a specific network of doctors. These plans, sometimes called MAPD plans, do accept all Medicare beneficiaries, and there are no health qualifications. If there is no Medicare supplement plan in your state (or you find them to be unaffordable), you can also look into Medicare Advantage plans. You also qualify if you are disabled, over age 50, and a widow or widower. Medicare will normally cover approximately 80% of your medical bills. Unlike Medicare by itself, these plans do have stop-losses that will prevent unlimited exposure to high medical expenses. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. BTo qualify, patients must have an annual income ≤150% of the federal poverty level, which is ≤$23,475 for single people or ≤$31,725 for married people. The Medicare Extra Help program provides assistance for people with low income. See if your benefits cover you for Wegovy®. Join the Live Well Magazine Newsletter and get exclusive tips on health, wellness, lifestyle, and personal growth — straight to your inbox. If you stay with Original Medicare (with or without a Medicare Supplement plan), then you need to buy the stand-alone Medicare Prescription Drug Plan (Part D). Part D is usually included in Medicare Advantage Plans, so there is no need to buy it separately. In other words, you need to compare Original Medicare with Medicare Advantage. If you decided to keep Medicare Part B, you now need to decide what Medicare plan type is best for you. If prescription drug coverage plans allow those with the highest cardiovascular risk scores to get full or partial coverage of the cost of semaglutide, another 5.1 million Americans could qualify the study finds. But exactly what level of cardiovascular risk should make someone eligible for such coverage, how many people could become eligible, and what could it cost the nation? Basic coverage provided by Medicare and Medicaid, which includes Part A (hospital insurance) and Part B (medical insurance). In 2024, the biden administration proposed a reinterpretation that could have opened the door to broader coverage for obesity as a chronic disease, but that effort was halted in 2025. During the Biden administration, it was proposed that Medicare prescription drug benefits cover weight loss drugs for obesity treatment. Several drugs have been approved by the Food and Drug Administration (FDA) to treat obesity over the long term. If the new employer provides health insurance, the employer insurance will become the primary payer (if there are more than 100 employees). If the company has 100 employees or more, the employer insurance will be primary (in other words, that insurance is billed first, and most likely covers more care than Medicare Part B). Wegovy is a GLP-1 agonist, a class of obesity drugs promising a sea change in weight loss. The plans may now cover Wegovy when prescribed to prevent heart attacks and strokes, according to a new policy issued this week from the Centers for Medicare and Medicaid Services. Advocates for groups such as the Obesity Society have been pushing for Medicare coverage of the medications for years. Doctors say weight loss drugs are only a part of the most effective strategies to treat a patient with obesity. If you’re considering weight loss medication, it’s a good idea to contact your insurance carrier to see what your plan covers, if anything. There is a new generation of safe, effective weight loss drugs shown to help people shed significantly more weight than previous medications. Medigap plans are generally for people over the age of 65, and insurance companies can refuse to sell Medigap policies to people under 65. Medigap plans do NOT include prescription drug coverage; therefore, you need to buy it separately. MA plans are required to provide the same Part A and Part B benefits as Original Medicare, but most plans include additional coverage, such as prescription drug coverage, vision and dental care, and fitness programs. Comparing Your Options: Private Insurance vs. Medicare Part D A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management, The New England Journal of Medicine. Once-Weekly Semaglutide in Adults with Overweight or Obesity, The New England Journal of Medicine. This is a set of eight patient-centered principles to ensure all Americans with obesity have access to the high-quality treatment options they need and deserve. Lawmakers and advocates are working to broaden access to affordable anti-obesity treaments. However, these medications still have high starting price tags of $499 and $349 per month, respectively. But those recommendations are problematic because BMI can under- or overestimate older adults’ body fat, the most problematic feature of obesity, noted Rodolfo Galindo, director of the Comprehensive Diabetes Center at the University of Miami Health System. (BMI is calculated based on a person’s weight and height.) There are no guidelines for their use in people 65 and older. The only thing that’s different is that some signal in my brain is telling me I’m hungry all the time,” Rich told me. “I feel horrible.” She knows that if she gains more weight, her care will cost much more. For detailed information about Medicare coverage options for weight loss medications, guidance is available to help beneficiaries understand their specific plan benefits and requirements. While federal regulations prohibit coverage for drugs used solely for weight loss, there are important exceptions and alternative coverage options that many people don’t know about. If your current private insurance covers a weight loss medication, starting treatment before you turn 65 could allow you to make significant health progress while you have coverage. These are the bundled plans (Part C) offered by private insurance companies that combine hospital (Part A), medical (Part B), and usually prescription drug (Part D) coverage. Lack of insurance coverage can prevent many people from accessing the full continuum of care for obesity. You may be able to return to work and keep your Medicare coverage if your disability responds to treatment. Part D out-of-pocket costs are capped at $2,100 per year in 2026, which includes plans that are part of a Medicare Advantage plan. Can you decline Medicare coverage? Once you turn 65 you will again have an open enrollment period for a Medicare supplement or Medicare Advantage plan. The medications reduce feelings of hunger, generate a sensation of fullness, and have been shown to help people lose an average of 15% or more of their weight. It’s one in a new category of medications changing how ordinary people as well as medical experts think about obesity, a condition that affects nearly 4 in 10 people 60 and older. The drug maker is among those pushing for Congress to expand coverage of treatments for obesity. It states that anti-obesity medications that receive FDA approval for an additional condition other than weight-management alone, can be considered a Part D drug for that specific use. And, Fitch notes, Medicare sets the standard for coverage in insurance generally, so this move could ultimately affect more patients. Even if you can’t buy a Medigap policy before age 65, you might consider enrolling in a Medicare Advantage plan, an alternative to original Medicare.Last year, about 40% of the nearly 66 million people enrolled in Medicare had obesity.They can also lower your risk of heart disease, diabetes, and other weight-related health conditions.He is passionate about making reliable health information accessible to all, and continues to help readers navigate the complexities of wellness and insurance in the digital age.Our experience shows that proactive planning during this 64th year is non-negotiable.“Under federal rules, Medigap policies are only required to be sold to people over 65,” says Whicheloe.Generally, the goal for older adults should be to lose 1 to 2 pounds a week, with attention to diet and exercise accompanying medication management.If your current plan covers a drug like Wegovy or Zepbound, this is your moment to work with your healthcare provider to begin treatment.This allowed them to calculate cardiovascular risk scores for every Medicare-enrolled person with a body mass index of 27 kg/m2 and above who didn't already have a history of heart attack, stroke, coronary artery disease or angina. Go here to see Medicare supplement plans available to those under age 65, by state. If there is no Medicare supplement plan in your state (or you find them to be unaffordable), you can also look into Medicare Advantage plans. That includes the right to coverage for treatment with access to the full range of treatment options. Multiple Medicare plans from the leading US insurance companies. You may consider enrolling in a Medicare Advantage (Part C) plan, which provides services covered by Parts A and B. Otherwise, you’ll have a premium penalty when you sign up for Part B later, and you may have a gap in your coverage. Can someone on Medicare at age 64 get weight loss medication covered? We work with beneficiaries across the nation and are glad to help you find the best coverage available. Call the phone number above if you’re ready to speak to someone about your Medicare coverage options. You can always file an appeal, but it is unlikely to be successful if the reason for denial is the statutory exclusion of weight loss drugs. Your coverage will change entirely. We provide a direct, transparent, and medically-supervised path to access GLP-1 medications like Semaglutide and Tirzepatide, ensuring you have continuity of care without insurance hurdles. The legislation has not yet been updated to reflect the modern medical understanding of obesity as a chronic disease and the development of new, effective therapies. Medigap plans only help pay for your share of costs (like copayments and deductibles) for services that Original Medicare covers. Novo Nordisk offers access to a health coach for diet and exercise to help people taking Wegovy. Drug manufacturers often have programs to help with drug costs and copayments for people without insurance. You typically need to have a certain BMI and participate in a weight loss coaching program. While Medicare isn’t mandatory, picking it up after lacking creditable coverage once you’re eligible will cost you. Results of such a choice can range from inadequate health coverage to feeling overwhelmed by the price of care. That means weight loss medications have real potential to provide relief and improve overall health for millions of older Americans. In 2025, nearly all health plans covered GLP-1s for diabetes and 49 percent of plans from companies with 500 or more employees for weight loss, according to Mercer’s National Survey of Employer-Sponsored Health Plans. The lower usage is likely because Medicare doesn’t cover prescriptions specifically for weight loss, the nonpartisan health policy nonprofit says. The long lead time for Part D participation allows plans to include GLP-1s in their drug coverage lists, update their computer systems and fine-tune their marketing before next year’s open enrollment Oct. 15 to Dec. 7. If successful, these pilots could lead to broader Medicare coverage for weight loss medications, potentially expanding access for millions of beneficiaries. The Centers for Medicare & Medicaid Services is testing pilot programs that could allow Medicare Part D plans to cover GLP-1 drugs specifically for weight management. The law itself, the very foundation of the Part D program, explicitly forbids coverage for medications used for the sole purpose of weight loss. They’ve finally found a solution that works, a medically-supervised path to sustainable weight loss, and now they face a potential coverage cliff at age 65. Many of these plans have recognized obesity as a chronic disease and cover the medications prescribed to treat it. Because private and employer-sponsored plans often have vastly different—and frequently more generous—rules for covering new-generation weight loss medications, often called GLP-1 agonists.