Does Medicare Cover GLP-1 Agonists?
Medicare currently excludes coverage of FDA-approved GLP-1 receptor agonists when prescribed solely for a diagnosis of obesity, but does cover these medications when prescribed for type 2 diabetes. 1
Coverage for Type 2 Diabetes
Medicare Part D plans cover GLP-1 receptor agonists (including semaglutide, tirzepatide, liraglutide, and dulaglutide) when prescribed for type 2 diabetes management. 2, 3 However, coverage comes with significant barriers:
Formulary Restrictions
Prior authorization requirements and step therapy (requiring patients to try less expensive medications first) are common barriers that limit access to these medications, though these restrictions have been decreasing since 2022. 4
Medicare beneficiaries enrolled in formularies with ≥2 GLP-1 agonists available in lower-cost tiers (1-3) had 17% higher odds of initiating treatment compared to those with no drugs in these tiers. 2
Following the 2022 American Diabetes Association guidelines recommending GLP-1 agonists as potential first-line therapy, formulary restrictions decreased substantially—GLP-1 agonists were 33.2% less likely to have restrictions at the formulary level after these guideline changes. 4
Out-of-Pocket Cost Burden
Medicare beneficiaries in the highest quartile of out-of-pocket costs were 13% less likely to initiate a GLP-1 agonist compared to those in the lowest quartile, with median time to initiation delayed by approximately 75 days. 3
Among low-income Medicare beneficiaries, mean out-of-pocket costs for GLP-1 agonists were $253 annually (range $0-$4,699), creating substantial financial burden. 5
Dual Medicare-Medicaid coverage was associated with 58% higher adherence to these medications, highlighting how full coverage improves medication-taking behavior. 5
No Coverage for Obesity Alone
Medicare explicitly excludes coverage of anti-obesity medications, including GLP-1 agonists, when prescribed solely for weight management. 1 This means:
Wegovy (semaglutide 2.4mg) is not covered for obesity treatment in non-diabetic patients, even though it reduces cardiovascular events by 20% in patients with established cardiovascular disease. 6
Zepbound (tirzepatide) for obesity is similarly excluded from Medicare coverage despite achieving 20.9% weight loss. 6
Patients must pay approximately $1,272-$1,619 per month out-of-pocket for these medications when used for obesity management. 6
Clinical Workaround: Dual Indications
For Medicare beneficiaries with both type 2 diabetes and obesity, GLP-1 agonists prescribed for diabetes management will be covered, providing the dual benefit of glycemic control and weight loss. 6 The brand names commonly used off-label include:
Ozempic (semaglutide injection) and Rybelsus (oral semaglutide) are FDA-approved only for diabetes, so insurance coverage is restricted to this indication. 1
Mounjaro (tirzepatide injection) is approved for diabetes only, with coverage limited to diabetic patients. 1
Disparities in Access
Age ≥75 years was associated with 77% lower odds of initiating a GLP-1 agonist compared to those under 65, indicating significant age-related barriers. 2
Black Medicare beneficiaries had 35% lower odds of initiating these medications compared to white beneficiaries, reflecting persistent racial disparities in access. 2
Critical Pitfall to Avoid
Do not assume Medicare coverage is uniform across all Part D plans—formulary design varies dramatically, with some plans placing multiple GLP-1 agonists on lower-cost tiers while others impose strict prior authorization requirements. 2, 4 Patients should compare Part D plans during open enrollment to select formularies with the most favorable coverage for these medications.