There are also plans for conditions including cancer, stroke, or kidney failure. These expenses include copays, coinsurance, and deductibles. There may also be quantity limits on how much medication Medicaid will pay for within a certain time period. It’s important to understand your insurance plan so you don’t get an unexpected bill. After that, most ongoing fills are $299 or $349 per month, depending on the medication and dose. 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. Navigating insurance coverage for innovative obesity treatments like Ozempic can be complex, but is possible. If your insurance initially denies coverage for Ozempic, especially for weight loss, you can file an appeal. If you're considering using Ozempic for weight loss, reviewing your plan's coverage for this medication is essential. Weight Loss Medications Medicaid coverage for weight-loss medications depends on the state you live in. Medicare is not allowed to cover weight-loss medications unless they are prescribed for other health reasons, such as reducing the risk of heart attack or stroke. Health insurance may cover treatments for conditions where overweight or obesity is a related issue. Among those companies, 28% of employers that have 5,000 or more workers and offer health benefits covered GLP-1 agonists for weight loss. Some health plans may approve surgery within two to four weeks, while others may have a lengthy approval process. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. All insurance policies and group benefit plans contain exclusions and limitations. If you don't have insurance or it doesn't cover these medicines, talk to your doctor or pharmacist. “This is unfortunate, because weight loss has been shown to result in improved health outcomes for patients, which overall, reduces healthcare costs.” (Mounjaro, with active ingredient tirzepatide, is similarly FDA-approved for treating type-2 diabetes, and yet is also prescribed off-label for weight loss.) And it's currently pretty hard to get the cost covered by health insurance. This discount is only available to people with a valid prescription who live in the U.S. If you have commercial insurance, you could pay as little as $25 per 1-month supply of Wegovy injections or pills, with maximum savings of $100 per 1-month prescription. But they aren’t FDA approved for chronic weight management. If you have Medicaid, your coverage will depend on where you live. To get coverage, you have to meet certain criteria, such as participating in a course like the MOVE! Alternative Medications and Treatments The buzzy medications can run up a super high cost for some.Knowing which medications your insurance covers can help guide your conversation with your healthcare provider.The first injectable drug is made by Huadong Medicine and the other one is by Benemae Pharmaceutical.The investigators stated that future research is needed to determine the long-term efficacy of using indirect calorimetry as part of a comprehensive weight control program.Although in this trial lorcaserin facilitated sustained weight loss without a higher rate of major cardiovascular events than that with placebo, the FDA reviewed that data and concluded that the potential risks of lorcaserin outweigh its benefits.Some states cover bariatric surgery and other treatments, while others do not.Broader coverage of pharmacotherapy can make a significant contribution to fighting this complex and chronic disease.In clinical trials, Wegovy was found to reduce risks of cardiovascular events by 20% in higher weight patients. Insurance plays a significant role in determining the cost of GLP-1 weight loss shots covered by insurance. The current state of insurance for weight loss shots covered by insurance shots shows we need a better plan. North Dakota will start covering weight loss shots covered by insurance medicines in 2025. Medicare typically doesn’t cover weight-loss medications, except for those used to treat other health conditions. The world of insurance for weight loss shots covered by insurance shots is undergoing rapid change. No weight loss plateau was observed during the 6-month GLOW study, and weight loss was sustained during a 24-week follow-up period.If an MCE is responsible for the payment of prescription drugs, referred to as being ‘carved in’ to the plan, then they work directly with pharmacies and pay their beneficiaries’ drugs needs with the lump sum received by the state’s Medicaid agency.22 Whereas, with an FFS model, the government provides the reimbursement for a drug directly to the pharmacy.Whether you’re going through insurance or a direct service like QuickMD, you typically need to meet clinical guidelines.Despite ongoing litigation, regulators continue to approve new uses for weight loss drugs.Notably, 13% of employers indicated they were considering coverage for weight loss.Utilization management tools are intended to balance cost control and access but may still pose barriers for people with a medical necessity to take these drugs.Some insurers may only cover certain GLP-1 brands, and not others. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Didrex is contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to sympathomimetic amines, and glaucoma. This Clinical Policy Bulletin addresses weight reduction programs and devices. A surge in demand from Medicare and Medicaid patients could put even more strain on that supply. But Medicare is prohibited from paying for weight-loss treatments so seniors have had to pay out of pocket for the drugs or use supplemental insurance. Wegovy is a GLP-1 agonist, a class of obesity drugs promising a sea change in weight loss. Musk has reportedly used Wegovy for weight loss in the past and recently tweeted that “nothing would do more to improve the health, lifespan, and quality of life for Americans than making” weight-loss drugs available at a “super low cost to the public.” Under the proposed rule, however, coverage of anti-obesity drugs would be compelled under both Medicare and Medicaid programs for enrollees classified as obese, which the U.S. Part D currently covers anti-obesity drugs only for obese enrollees who have also been diagnosed with concurrent medical conditions such as cardiovascular disease or Type 2 diabetes. Other than orlistat (Xenical), which is approved for use in adolescents aged 12 years or older, weight reduction medications have not been proven to be safe and effective for treatment of obesity in children and adolescents. Twenty-five years ago, the Clinton administration expanded coverage to include weight gain drugs to help people with AIDS, who were also suffering from wasting syndrome. That's because of legislation written decades ago that specifically excludes drugs for weight loss from mandatory coverage. However, doctors have been prescribing Ozempic “off-label” for weight loss, says Dr. Russo. But these buzzy drugs, which are meant to be "lifelong" drugs taken long term, aren't cheap. The buzzy medications can run up a super high cost for some. One option is to consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat. Given previous bipartisan, bicameral support for lower healthcare costs, Kennedy Jr.’s position on the proposed rule could feature prominently in his future confirmation battle. Despite the proposed rule’s clear benefit to Medicare and Medicaid enrollees, some commentators have expressed the concern that the proposed rule would classify obesity itself as a “chronic illness” at a cost to the obese community. But even paying $2,000 out of pocket would still be beyond the reach of many people with Medicare who live on modest incomes. Treasury Confirms $602 Billion Deficit in First Three Months of FY 2026 However, if Medicare were to cover these medicines, it would cost the federal government approximately $35 billion from 2026 to 2034. Although some progress has been made, it remains challenging to access these treatments for everyone. They must ensure more widespread and affordable access to these life-changing treatments. Medicaid has experienced a significant increase in GLP-1 prescriptions and spending in recent years. These medications may also be costly. Check your TRICARE plan for details on coverage and criteria. TRICARE is the federal health insurance for U.S. military members and their families. To find out what’s covered and the specific requirements, check your state Medicaid formulary. For example, some states list Wegovy as a preferred medication on their formularies, but you may need prior authorization before Medicaid will cover them. The newer FDA-approved obesity medications tend to be covered as tier 3 medications. We investigated each plan’s formularies to determine coverage for the FDA-approved obesity medications listed in Table 1. For the first time, Medicare will allow coverage of one of the new blockbuster weight-loss drugs for enrollees in Part D plans. The shift in coverage could potentially be significant for millions of obese Americans who otherwise could not afford semaglutide-based medications—“miracle drugs” like Ozempic and Wegovy. The Biden Administration has proposed a new rule that would expand Medicare and Medicaid coverage for enrollees seeking prescription drugs popularized in recent years as weight-loss expedients. Balazs (2010) stated that the rapidly increasing prevalence of over-weight and diabetes mellitus is a serious global threat to healthcare. Xenical (orlistat) is indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced‐calorie diet. If weight is lost in the initial 6 months of therapy or is maintained after the initial weight loss phase, this should be considered a success and the drug may be continued. Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity. Brooks-LaSure says it would be about 1% of the money spent during that time on prescription drugs for Medicare and 2% on Medicaid. Policy Limitations and Exclusions Not all GLP-1s are approved for obesity treatment, and this analysis includes all FDA-approved GLP-1s, including those approved for obesity (Saxenda, Weogvy, Zepbound) as well as those approved for type 2 diabetes (see Table 1).“This is unfortunate, because weight loss has been shown to result in improved health outcomes for patients, which overall, reduces healthcare costs.”Have you tried diet and exercise but haven't been able to lose enough weight?Whiting et al (2014) stated that capsaicinoids are a group of chemicals naturally occurring in chili peppers with bioactive properties that may help to support weight management.Advocates suggest working with healthcare providers to find more affordable options and advocating for improved coverage from insurers and employers.Didrex should not be used in combination with other anorectic agents, including prescribed drugs, over-the-counter preparations and herbal products.The agency's guidance means Medicare patients could soon get coverage for Wegovy, as long as they have obesity and a history of heart disease and are prescribed the treatment to reduce their risk of heart attacks and strokes. To put that in perspective, if just 10% of eligible Medicare patients used Wegovy, the system could see an added $13 billion in spending annually. And that’s more than a personal problem; it’s an issue that affects the healthcare system as a whole. It raises the risk of developing diabetes, heart disease, sleep apnea, joint deterioration, and several types of cancer. A CMS spokesperson told CNBC last week that Medicaid programs would be required to cover Wegovy specifically for its new cardiovascular use. Earlier this month, the Food and Drug Administration approved Wegovy for that purpose. Learn healthy meal combinations and smart portion control to achieve your fitness goals You can look up a doctor near you for in-person care or find a doctor online (telehealth). Please make sure the FDA-approved indication requirements are met. Your doctor will need to submit a form to your insurance company to get approval for Wegovy®. If you don't have insurance, there are 2 ways to get Wegovy® for less. According to the CBO, sales of anti-obesity medications stood at $1.1 billion for the second quarter of 2023. From 2020 to 2022, prescriptions for these medications increased by 300%. Some GLP-1 agonists, as well as other medications like orlistat and Qsymia, are approved for ages 12 and older. Another argument for coverage is obesity's link to cardiovascular and other related diseases. The active ingredient in Ozempic, semaglutide, does work for weight loss, according to research. Other insurers may limit coverage to control costs. You may also be able to get a prescription for Wegovy online, using a telehealth service. Yes, accessing Wegovy requires a prescription from a licensed healthcare professional. People covered by government-sponsored programs — such as Medicaid, Medicare, Medigap, Tricare, or VA benefits — aren’t eligible. However, an off-brand version of the drug has been seen at compounding pharmacies across the U.S. The FDA warns people of the dangers of using "generic" Ozempic and Wegovy. Read about primary care and why you should partner with a provider for your health It's crucial to contact your state's Medicaid program to understand the extent of coverage available for Ozempic, especially when considering it for weight loss. Medicare typically covers Ozempic under Medicare Part D for treating type 2 diabetes but does not cover it for weight loss. However, coverage for weight loss is less certain since this is considered an off-label use. While Ozempic's primary FDA-approved use is for managing type 2 diabetes, its effectiveness in aiding weight loss has been recognized. Ozempic may be used alone or with other FDA-approved diabetes medications like metformin, sulfonylureas, thiazolidinedione, and insulin. Paying for these treatments out-of-pocket isn’t an option for many people due to high costs. It is often recommended that you try oral medications before moving on to GLP-1 injectables. But they may help you make the lifestyle changes that you need to practice to lose weight and improve your health. The other drugs in this group aren't often prescribed. For insurers, the high cost of covering these drugs for a large population still outweighs the clinical benefits in their short‑term budgeting.With persistence and the right approach, you can achieve your weight loss goals without breaking the bank.Cigna may cover certain weight loss medications when medically necessary, but only under select plans.First, you need to confirm your insurance plan covers the cost of GLP-1 medications for any patient.Concurrently, the Food and Drug Administration (FDA) approved several new drugs for the short and long-term treatment of obesity.Ozempic is primarily used to treat Type 2 diabetes, but some doctors prescribe it for weight loss, too.We identified each state’s Preferred Drug List and their pharmacy and provider policy handbooks to formulate an accurate picture of the coverage offered by each state within their Medicaid health insurance plans.2025 Delaware Medicaid preferred drug list (PDL). Its effectiveness in causing weight reduction in humans has not been fully established. In a systematic review, Onakpoya et al (2014a) evaluated the evidence for or against the effectiveness of glucomannan, a soluble fiber, in body weight reduction. Subsequently, there may be potential for capsaicinoids to be used as long-term, natural weight-loss aids. The authors concluded that more studies are needed to determine the best field body composition method to monitor changes during overweight treatment in children and adolescents. These investigators reviewed available information on the short- and long-term effects of intervention treatment on body fat composition of overweight and obese children and adolescents and, to obtain a further understanding on how different body composition techniques detect longitudinal changes. However, Saxenda is not indicated for the treatment of type 2 diabetes, as the safety and efficacy of Saxenda for the treatment of diabetes has not been established (Novo Nordisk, 2020). In this trial, 49 percent of patients treated with liraglutide lost at least 5 percent of their body weight compared with 16 percent of patients treated with placebo. In this trial, 62 percent of patients treated with liraglutide lost at least 5 percent of their body weight compared with 34 percent of patients treated with placebo. Some only cover specific GLP-1 drugs or may stop paying if you don’t meet certain progress markers over time. Surveys show that roughly 44% of large employers, and 64% of even larger employers (those with over 20,000 workers), now cover at least some GLP-1 medications. So, will your insurance cover a GLP-1 medication? In 2003, Medicare part D was launched to help manage prescription drug costs as part of the Medicare Modernization Act. Since drugs like tirzepatide and semaglutide are meant to be taken indefinitely, starting one is a financial commitment. Several newer medications, mainly GLP-1 receptor agonists, have been introduced. How are prescription drug prices determined? They may be well versed in what’s covered and what’s required to get approval. Since many of these medications are relatively new and obesity wasn’t recognized as a disease until recently, not all health insurance companies cover them. Members who qualify have access to weight-loss medications, including the latest GLP-1s, for much less than the list price — even without insurance coverage. Or the type 2 diabetes drug Rybelsus, which is an oral version of semaglutide that can result in weight loss even though it’s only FDA-approved for managing blood sugar in people with diabetes. As proposed, coverage of the drugs would end on Jan. 1, 2026. Medicaid coverage for weight loss varies by state. His company also is heavily lobbying Congress to pass legislation to allow Medicare to cover obesity medications. Many programs also require prior authorizations before covering weight-loss medications. For example, your state may not cover Wegovy, but it may cover a medication that’s FDA approved for chronic weight management, such as Saxenda (liraglutide). Some benefits are mandatory and must be provided by each state’s Medicaid program, while other benefits, such as prescription medication coverage, are optional. Medicaid is a joint federal and state program that provides health insurance coverage to eligible low-income individuals and families in the U.S. As mentioned, whether or not Medicaid covers weight-loss medications depends on the state running the program. Laws like the Treat and Reduce Obesity Act of 2023 might make these drugs more available and affordable. Although coverage is currently limited, things may improve. Patients need to know what their insurance covers and how much they might have to pay. This is because more people want them, and they might help with health. With more people becoming obese, there’s a big push to find ways to help manage weight. GLP-1 medications are appetite suppressants that cause people to feel full.Whether Medicaid finances a health insurance plan with an FFS model or under an MCE, they both operate under the state’s approved prescription drug formulary and the state’s Preferred Drug List.Garvey et al (2012) conducted a placebo-controlled, double-blind, 52-week extension study to evaluate the long-term efficacy and safety of controlled-release phentermine/topiramate (PHEN/TPM CR) in overweight and obese subjects with cardiometabolic disease.Counsel patients regarding the potential risk of MTC and the symptoms of thyroid tumors (Novo Nordisk, 2020).Pharmacologic treatment of exogenous obesity should be adjunctive to caloric restriction, increased physical activity, and behavioral modification.MHRA to investigate links between genetics, GLP-1 drugs and pancreatitisIn response to growing criticism of the cost of their drugs, Novo Nordisk, the company that manufactures Ozempic and Wegovy, reported last year that rebates and other fees (across all payers) accounted for about 40% of the cost of the two drugs and that they expected rebates to grow. Does Medicaid Cover Dental Care? There are significant differences in what commercial plans, Medicare, and Medicaid cover. Only 1% of Marketplace plans cover Wegovy, while 82% cover Ozempic. To lose weight, you need a healthy diet, regular exercise, and more exercise. GLP-1 drugs are usually safe but can cause side effects like nausea and diarrhea. The SCALE phase 3 clinical trial program of the safety and effectiveness of liraglutide for chronic weight management included three clinical trials that included approximately 4,800 obese and overweight patients with and without significant weight-related conditions (FDA, 2014). Trial data showed that liraglutide, in combination with a reduced-calorie diet and increased physical activity, resulted in significantly greater weight loss than diet and physical activity alone. The FDA approved liraglutide rDNA origin injection (Saxenda), a once-daily injection of a glucagon-like peptide-1 (GLP-1) receptor agonist, for chronic weight management (Novo Nordisk, 2014). The authors concluded that the evidence from available RCTs does not show that glucomannan intake generates statistically significant weight loss. UnitedHealthcare may limit the quantity or duration of medication coverage. Requirements usually include a qualifying BMI, documentation of obesity-related health risks, and previous lifestyle treatment efforts. Coverage is most likely in employer-sponsored or marketplace plans that include obesity treatment benefits. Some BCBS affiliates include medications like Wegovy or Zepbound when prescribed for clinically obese patients who meet strict medical necessity guidelines. Many insurers require prior authorization before approving weight loss medication. While their adoption brings undeniable public health benefits, the rapid pace of adoption positions them as an emerging risk with complex legal, regulatory, and insurance implications.However, there are ways to appeal, such as manufacturer assistance programs or exploring other coverage options.Plans often require a high BMI or obesity diagnosis.Studies that included patients with altered body composition or a disturbed fluid balance and studies written in languages other than English were excluded.As a result, more people need to jump through extra hoops to access these medications, despite having insurance.Reasons patients give for stopping include reaching a plateau in weight loss, inability to tolerate side effects, or even inability to get the medication due to shortages.The guidance also will open the door to future coverage of other weight loss medications, many of which are being tested for additional health conditions. For Medicare enrollees, weight loss drugs are never covered. Some health plans may require weight loss milestones to continue coverage, while others may terminate coverage if the patient successfully loses enough weight. Some health plans require evidence that weight loss strategies such as exercise or diet changes have not worked previously, while other plans may require a coinciding behavioral weight-loss program if coverage is provided. GLP-1 drugs, including Ozempic, Trulicity, Victoza and Mounjaro, are used to treat Type 2 diabetes, while Wegovy and Saxenda are approved for weight loss. Various websites and organizations offer resources for low-income families or those without insurance. Novo Nordisk also offers a Patient Assistance Program (PAP), which provides free medication to those who qualify. The Novo Nordisk Savings card can provide maximum savings of up to $450 for a 3-month prescription, valid for up to 24 months after card activation. This program, however, does not apply to people using government-assisted programs such as Medicare or Medicaid. Novo Nordisk, the manufacturer of Ozempic, offers a copay assistance program for individuals with commercial insurance. Notably, 76% of older adults think Medicare should cover prescription medication for weight management, according to recent findings from the National Poll on Healthy Aging.How coverage usually worksThis could involve demonstrating that you’ve completed nutrition counseling, exercise, or other weight management activities.Weight loss drugs Ozempic and Wegovy would no longer be covered by California’s health insurance for low-income people under the governor’s proposal.North Carolina’s State Health Plan spent $100 million on GLP-1s for weight loss in 2023.Many people and companies wonder if insurance will cover them.These investigators reviewed available information on the short- and long-term effects of intervention treatment on body fat composition of overweight and obese children and adolescents and, to obtain a further understanding on how different body composition techniques detect longitudinal changes. Medicare Part D excludes medications used for weight loss, even though some of these same drugs are now FDA-approved to reduce heart disease risk. Medicare, which serves people over 65, currently denies coverage for weight loss drugs like Wegovy or Zepbound. Our licensed providers regularly help patients using weight loss medications, and we understand the real-world challenges of accessing them, especially when coverage is unclear or unavailable. One woman in Washington sued the state agency in charge of purchasing health insurance for public employees after she was denied weight loss medication coverage. If you’re considering using medication to help you lose weight, it’s important to talk to your doctor about what this would look like for you, including health insurance coverage options. There's a whole lot to wade through when it comes to health insurance and weight loss drugs. The patients in this study had their medications covered by insurance, so cost may not have been a factor. Some providers have prescribed GLP-1 agonists approved for diabetes off-label, but pharmaceutical companies are increasingly pursuing approval of the drugs specifically for weight loss. Some medications are approved for people with obesity, while some are also approved for people classified as having overweight but not obesity. If you have commercial insurance that does not cover Wegovy, you could pay $349 for a 1-month supply of the injection. Without coverage, Wegovy can cost around $16,000 or more annually. At that time, it became the first weight-loss medication to gain this indication. Wegovy was also approved in March 2024 to help prevent heart attacks, strokes, and heart-related deaths in adults with a cardiovascular condition who are considered either overweight or obese. Should there be limitations such as someone who has an obesity diagnosis, or BMI over a certain limit? "Every employer would love to cover everything to make everybody happy, but somebody's got to pay for it." If you've got, say, 56 employees on the drug, that's over $1 million a year. Wall Street's most optimistic assessment sees a drug that can post more than a billion dollars in sales in its first year on the market and eventually become the biggest drug of all time. We cannot diagnose conditions, provide second opinions or make specific treatment recommendations through this website. Lost Medicaid? What to Do Next to Keep Getting Your Prescription Medications It’s unlikely that a supplemental health insurance plan would cover weight-loss medications, but it depends on the policy. In the future, Medicare could begin covering weight-loss medications for obesity treatment more broadly if the Treat and Reduce Obesity Act is passed by Congress. However, if you're prescribed these medications off-label for weight loss, coverage may be less likely. For instance, if you have Type 2 diabetes, your insurance might cover medications such as Ozempic or Mounjaro (tirzepatide), since they are FDA-approved for Type 2 diabetes management. For example, Wegovy, an injectable medication approved for chronic weight management, may be covered by certain Blue Cross Blue Shield plans if you meet specific criteria. Many insurance companies and employers that provide healthcare coverage don’t consider weight-loss medications medically necessary. Medicare plans are prohibited by law from covering prescription medications taken solely for weight loss. On top of that, many Americans are caught in a “Big Pinch” as insurance plans cut back on coverage and place more restrictions on the medications that are covered. If you have Medicaid or a commercial plan, you may lose coverage for weight‑loss use, though drugs prescribed for type 2 diabetes generally remain covered. Some plans don’t cover these medications for weight loss at all unless you also have diabetes. Weight-loss medicines may be an option for people who have obesity or who are overweight and have weight-related health problems, such as high blood pressure or diabetes. If it becomes official coverage policy, this change would also lift the burden off lawmakers in Congress who have repeatedly introduced legislation to authorize Medicare coverage of anti-obesity drugs but who may have been stymied by the potential cost of doing so. While coverage would be available for Medicare and Medicaid enrollees with obesity, Medicare Part D drug plans and state Medicaid programs could still apply utilization management tools such as prior authorization, which could limit access. But even with these coverage limits in place, gross spending on these drugs for approved uses in Medicare and Medicaid has skyrocketed in recent years, totaling $4 billion in Medicaid in 2023 and close to $6 billion in Medicare in 2022 for selected GLP-1s. This reinterpretation reflects an evolution in the understanding of obesity as a disease and weight loss as conferring real health benefits in people with obesity rather than being merely for cosmetic purposes. However, coverage is often subject to strict criteria, such as a minimum BMI, documented comorbidities, and failed attempts at diet and exercise alone. Dr. B helps patients get affordable care and everyday prescriptions, while expanding access to those who need it most. As their costs differ, so does their coverage! If they don’t cover the medication your provider recommends, ask to discuss a different kind of medication or a different GLP-1. Around 30-35% of prior authorization requests for GLP-1 treatment are approved. From Medicaid data publicly available, there is no way yet to disentangle how much of the growing use of GLP-1s is related to treatment for diabetes, cardiovascular disease, or sleep apnea versus obesity, or a combination. Prescriptions and spending on Ozempic, approved for type 2 diabetes (not obesity) in 2017, have grown considerably over the period. North Carolina eliminated GLP-1 coverage beginning October 2025 due to a budget stalemate in the legislature, but coverage was reinstated in December 2025, bringing the total number of states covering GLP-1s for obesity to 13 as of January 2026. For Medicare Part D, this model will be implemented in January 2027, following a separate short-term demonstration that will allow Medicare Part D enrollees to access obesity drugs beginning in July 2026. Questions on coverage? Healthcare providers consider various factors, including cost, in determining whether to prescribe an off-label medication, says Dr. Charlie Seltzer, M.D., an obesity specialist based in Philadelphia. These high prices are due, at least in part, to the fact that many of these drugs don’t have a generic version yet, which tends to bring prices down when it becomes available. We’re living in a golden age of weight-loss drug innovation. If coverage is still denied, you can explore other ways to reduce costs, such as using a GoodRx coupon or applying for a patient assistance program. For those who don’t have Medicare, approval delays may happen because many weight-loss medications are still relatively new, particularly the GLP-1s. Although Medicare represents only those over age 65, it sets a tone for insurance companies about what should be covered. That means 65 million people in the U.S. who are on Medicare are not covered. Lower tiered drugs tend to be generic and often are included in the plan’s drug formulary, in which case the co-payment is lower and often does not require prior authorization. When reviewing each states’ Medicaid Excluded Drug Coverage information, by default, all lists included the statement ‘Drugs when used for anorexia, weight loss, or weight gain.’ If there were an exception to this statement it would be listed below the statement. We identified health plans for individuals and families and assessed the four silver plans we mentioned above. For each state, we first chose the most populous county based upon number of enrollees.15 We then used 2016 Qualified Health Plan (QHP) Landscape Data,16 which includes data from health plans from states participating in FFMs and SPMs. We chose silver plans, because according to 2016 enrollment data, 71% of enrollees using healthcare.gov chose silver plans.14 If the state added a favorable statement providing an exception to the default statement that included coverage for an obesity medication, the state received a score of ‘1.’ If the state included an unfavorable statement that specifically excluded an obesity medication the state received a score of ‘− 1.’ It would include a list of drugs or it would include the drug class that was not excluded from coverage. Since some of the excluded drug coverage policies for each state were updated as recently as 2009, we also investigated each state’s individual Medicaid program’s prescription drug policies and coverage, which are updated on an annual basis. However, our body’s adaptive biologic responses to weight loss leads to altered physiology that ultimately results in weight regain.7 Clinical guidelines reflect this knowledge and do not recommend lifestyle and behavior modification for the treatment of obesity alone. At the end of 1 year of therapy with Plenity, 67 % of subjects achieved at least 5 % weight loss. At the time when weight regain is expected, the subjects who successfully lost with lifestyle modification were able to lose an additional 3% ± 4% over the subsequent 24 weeks with the addition of Plenity treatment. The additional six months of exposure to Plenity provided an additional 0.8% ± 3% weight loss and demonstrated maintenance of the weight loss effect. At the time of enrollment in GLOW-EX, the subjects treated with Plenity during GLOW had already reached a mean (SD) weight loss of 7 % ± 3 % weight loss in 24 weeks. The objectives are intended to evaluate 1) safety of one year exposure to Plenity, and 2) efficacy of Plenity to maintain weight loss achieved after 6 months of Plenity combined with diet and exercise. Medicare doesn’t cover weight-loss drugs unless for the treatment of diabetes. However, employer plans may cover GLP-1 medicines for weight loss shots covered by insurance in approximately 25% of cases. Insurance coverage for weight loss medications varies significantly. The world of insurance for weight loss shots covered by insurance treatments is undergoing rapid change. When we view obesity as a disease process affecting a person’s metabolic and hormonal homeostasis, we may begin to accept pharmacotherapy as a solution.5,26,27 One views obesity as a reflection of a person’s self-control or nutrition status, which prevents the adoption of pharmacotherapy. These were Alabama, North Dakota, South Carolina, South Dakota, Texas, Virginia, Wisconsin and Delaware, but they do require prior reauthorization and extensive medical evaluation for demonstration of treatment need. Through the ACA, states are eligible for an enhanced federal Medicaid matching rate if their programs cover preventive services with no cost sharing to the beneficiary.4 The new model will include standardized coverage criteria as well as lifestyle supports and is voluntary for state Medicaid programs, Medicare Part D plans, and manufacturers. In December 2025, the administration also introduced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) model, a five year CMS Innovation Center (CMMI) model that intends to expand access to obesity drugs in Medicaid and Medicare by negotiating lower GLP-1 prices with manufacturers. This brief discusses the current landscape of Medicaid GLP-1 coverage and examines recent trends in Medicaid prescriptions and gross spending on GLP-1s. The upfront costs of GLP-1s are an ongoing concern for both public and private payers, and some employers and state Medicaid programs are now restricting coverage, despite recognizing their effectiveness at treating obesity. Tests with weight loss drugs have shown that initial responders tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. Weight reduction medications should be used as an adjunct to caloric restriction, exercise, and behavioral modification, when these measures alone have not resulted in adequate weight loss. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion. Wegovy (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist that was FDA approved in 2021 for chronic weight management. Increased restrictions for many GIP and GLP-1 agonists has further limited access to these medications. That means if they are prescribed Wegovy, Zepbound, or Saxenda, their insurance will not cover it. This is particularly true for Saxenda, which is the only brand of liraglutide prescribed specifically for weight loss. Yes, most insurers want your doctor to show you have a BMI of 30 or higher to consider obesity treatment options like Ozempic. Though the process poses challenges, arming oneself with comprehensive strategies empowers patients to advocate for medical care that could profoundly improve their health. Make an appointment to discuss your treatment options with your healthcare provider. Savings card, cost, and coverage support. Once weekly semaglutide in adults with overweight or obesity. FDA approves new medication for chronic weight management. Lilly's tirzepatide shows additional 21.1% weight loss after 12 weeks of intensive lifestyle intervention, for a total mean weight loss of 26.6% from study entry over 84 weeks. A manufacturer savings card for Ozempic is available to people with Type 2 diabetes. Why some are willing to pay out of pocket Semaglutide GLP1 medications are administered through once-weekly injections under the skin, starting with smaller doses that increase gradually over time with doctor supervision. Lots of folks are concerned about access to GLP1 medications like Ozempic, Monjouro and Zepbound. Sometimes, mail-order specialty pharmacies may offer lower copays or discounts on Ozempic and other expensive drugs. Approvals typically last 6-12 months if authorized, after which you'll need your doctor to request renewal to keep coverage. 32% use step therapy, requiring cheaper drugs first. Seventy-nine percent of companies require prior approval for GLP-1 drugs. Self-insured plans have more freedom in what they cover. People with employer coverage pay approximately $70 per month for semaglutide. Eighty percent of Wegovy patients with commercial insurance pay $25 or less per month. And adults who have an established heart condition and either obesity or overweight can get coverage if they’re prescribed the medication to reduce the risk of major cardiovascular events. Therefore, you’ll have to reach out to your state Medicaid agency to determine if Ozempic is covered for weight loss if you do not have Type 2 diabetes. For example, if you want to take Ozempic to lose weight, but you don’t have Type 2 diabetes or another FDA-approved indication, you may have issues getting Ozempic covered. In addition to deciding whether their program will cover weight-loss medications, states can select which medications will be covered.