GLP-1 medications like Wegovy and Zepbound have gained attention for helping people lose weight and improve long-term health. These same medications are used to treat diabetes under Medicare, but when used for weight loss, they fall outside of coverage. This decision from the Centers for Medicare & Medicaid Services (CMS) has sparked questions about fairness, access, and how we define medical care. Many older adults and caregivers are wondering what this means and how to move forward.
The CMS Decision: What Changed and Why It Matters
CMS has announced it would not approve a rule that aimed to expand Medicare coverage to include GLP-1 medications for weight loss. The original proposal, introduced by the Biden administration, would have given older adults with obesity access to medications like Wegovy and Zepbound. CMS did not explain the reversal, but the decision immediately affected millions of people.
Medicare still covers GLP-1 drugs when prescribed for type 2 diabetes or certain heart conditions. However, if someone receives the same drug for weight loss, Medicare will not pay for it. This leaves many patients facing a choice between paying out of pocket or skipping treatment. For people already managing chronic conditions, that choice feels unfair and frustrating.
Why the Same Drugs Receive Different Treatment
The U.S. Food and Drug Administration (FDA) approves drugs for specific uses. Ozempic, for example, is used to treat diabetes. Wegovy contains the same active ingredient as Ozempic but is approved for weight loss. The medications work in similar ways, but the difference in approval changes how Medicare handles coverage.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 blocks Medicare from covering drugs used for weight loss. At the time, obesity was not widely seen as a disease. Today, that understanding has changed, but the law has not.Â
Medicare can only cover these drugs if the patient has another qualifying condition, such as diabetes or cardiovascular disease. Without that second condition, Medicare cannot pay for the prescription, even when the drug itself is FDA-approved.
How GLP-1 Drugs Work and Why Doctors Use Them
GLP-1 medications help the body manage blood sugar, slow digestion, and reduce hunger. These effects help people with diabetes control their symptoms and help people with obesity lose weight. For many patients, the results are life-changing.
Doctors first used these medications to treat diabetes, but as research grew, new benefits became clear. In 2021, the FDA approved Wegovy for weight loss. More recently, studies have shown that GLP-1 drugs may reduce the risk of heart attacks, strokes, and even sleep apnea. In March 2024, the FDA approved Wegovy to lower the risk of heart problems in people who are overweight or obese and already have heart disease.
This growing list of benefits has led to more doctors recommending GLP-1 medications for weight loss. However, many of those patients cannot get help paying for the medication unless they meet Medicare’s limited criteria.
Access and Affordability Remain Major Obstacles
Even when a patient qualifies, access is not guaranteed. Medicare Part D plans use different drug lists called formularies. Some include GLP-1 medications for diabetes or heart disease. Others do not. Even within plans that offer these drugs, patients may need to go through extra steps, such as prior authorization. This process can delay treatment or add paperwork for patients and providers.
Enhanced Medicare Advantage plans sometimes include additional drug options, but they usually cost more each month. These plans are not available to everyone and do not always include weight loss medications.
Patients who do not have diabetes or a heart condition face even greater challenges. Many cannot afford to pay for these prescriptions out of pocket. Even patients with qualifying conditions sometimes struggle to fill their prescriptions because of shortages and demand. These barriers leave people stuck—interested in a treatment that works but unable to access it.
How This Decision Affects Public Health
Obesity affects millions of Americans and increases the risk of heart disease, diabetes, and joint problems. Many doctors and public health experts believe that Medicare should cover treatments for obesity just like it does for any other chronic illness.
Policy advocates are pushing for laws that would change Medicare’s rules and make these drugs available to more people.
One of those efforts is the Treat and Reduce Obesity Act. The bill would allow Medicare to cover prescription drugs for obesity, including GLP-1 medications. It passed committee review in 2024 but has not yet become law.
This debate touches on a bigger question: Should Medicare continue to limit coverage based on outdated laws, or should it adjust to what doctors and researchers now understand about weight, health, and disease?
What the Future Might Look Like
Right now, Medicare limits who can receive coverage for GLP-1 medications. But change is possible. The Treat and Reduce Obesity Act, if passed, would make more people eligible. The Inflation Reduction Act has already given the Department of Health and Human Services more control over drug pricing, which may shape future coverage as well.
GLP-1 medications remain expensive, and many experts believe patients will need to use them long-term to maintain benefits. Because of this, lawmakers are still weighing the cost of expanding coverage. As demand continues to grow, Medicare and other agencies will need to address these questions head-on.
For now, access depends on diagnosis, location, and the fine print of each insurance plan. Patients and caregivers need to know the current rules and keep an eye on possible updates.
Talk to Zeam About Your Weight Loss Options
At Zeam Health & Wellness, we believe everyone deserves access to safe, supportive care. We help patients understand their options, including programs that do not rely on weight loss prescriptions.
We offer primary care and medically supervised weight management services in both Folsom and Roseville. Our care teams work with each patient to create a plan that fits their health needs and goals.
If you have questions about GLP-1 medications, eligibility, or alternatives, we are here to help. Contact us to schedule a visit and learn more about our approach to weight loss and long-term wellness.
