How does Medicare cover GLP‑1 medicines like Ozempic, Wegovy and Zepbound?

Which part of Medicare pays for GLP‑1 medicines?

Part D, the drug coverage you get from a private plan, pays for GLP‑1 medicines you inject or swallow at home, not Part B.^5,4

Part B is the medical part of Medicare. It covers drugs you wouldn’t usually give yourself, such as those given in a doctor’s office or hospital clinic.⁵ Weekly pens and daily pills are taken at home, so they usually fall under Part D.⁵

You can get Part D in one of 2 ways:⁴

• A separate drug plan added to Original Medicare (Parts A and B, run by the federal government).
• A Medicare Advantage plan (Part C), which bundles Parts A and B and usually Part D. If your Advantage plan has no drug coverage, in most cases you can’t add a separate drug plan.

Either way, the plan follows Medicare’s rules but chooses its own drugs and costs.⁴ Part B does pay for weight counseling from your primary care provider if your BMI (body mass index, a measure of weight for height) is 30 or more. It costs nothing if the provider accepts Medicare’s rates.⁶

Which uses of a GLP‑1 can a Medicare drug plan cover?

A Part D plan can cover a GLP‑1 for an approved use, such as diabetes, heart risk or sleep apnea, but not weight loss alone.^1,3

Federal law lets drug programs exclude medicines “when used for anorexia, weight loss, or weight gain”.² Part D’s definition of a covered drug leaves out those uses.³ KFF, a health-policy research group, says Medicare “has been prohibited by law from covering medications when used specifically for weight loss”.¹

The ban follows the reason for the prescription, not the medicine.³ So a plan can cover the same medicine for another use on its FDA label (the official prescribing information).¹

Plans can cover these uses, and each sets its own rules. Sources: US labels; KFF, May 11, 2026; Medicare.gov fact sheet, June 2026.

Each plan picks its own drugs and may ask for proof of the use first.^4,15 From January 1, 2027, the law requires every Part D plan to put Ozempic, Rybelsus and Wegovy on its drug list, because Medicare negotiated their price.¹³ That still covers only the uses above, not weight loss alone.³ More detail: Wegovy for heart and fatty liver and Zepbound for sleep apnea.

Where does the $50 Medicare GLP‑1 Bridge fit in?

The Bridge is a separate, temporary Medicare program for weight use only, so it sits outside your Part D plan and its rules.^9,7

It covers Foundayo, Wegovy injection or tablets, and the Zepbound KwikPen at $50 a month, “no matter your income level”.⁷ Single-dose Zepbound pens and vials are not covered.⁷ It runs through December 31, 2027; KFF says it is uncertain what happens after that.¹

You need Part D to use it, through a separate drug plan or a Medicare health plan with drug coverage.⁷ Because it sits outside Part D, 4 plan rules don’t apply to the $50:^9,7

• the Part D deductible;
• the yearly out-of-pocket cap, which the $50 doesn’t count toward;
• Extra Help, the low-income subsidy;
• the Medicare Prescription Payment Plan.

People with type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease can’t use the Bridge. Medicare tells them to contact their drug plan, which “may already cover” a GLP‑1.⁷ If your plan has paid for a GLP‑1 “for any reason”, you keep getting it through the plan.⁷ The BMI rules and the steps are in the Medicare GLP‑1 Bridge explained and who qualifies for the Bridge.

What will you pay for a GLP‑1 through Part D in 2026 and 2027?

Your plan’s deductible and copays apply until your yearly costs reach a cap, which is $2,100 in 2026 and $2,400 in 2027.^10,11

A Part D year has 3 stages, says Medicare:¹⁰

• Deductible: you pay the full cost until you reach it. No plan’s deductible can be above $615 in 2026 or $700 in 2027; some plans have none.
• Initial coverage: Medicare says you pay 25% of the cost (coinsurance), until your spending reaches the cap. Your plan’s drug list sorts drugs into tiers (price levels), and each tier has its own copay or coinsurance.²⁷
• Catastrophic coverage: after the cap, you pay nothing for covered Part D drugs for the rest of the calendar year.

The 2027 negotiated price. Medicare negotiated a price for Ozempic, Rybelsus and Wegovy; the law calls it the maximum fair price. From January 1, 2027, it is $274 for a 30-day supply.¹³ The 2024 list price was $959, so that is 71% lower.¹³ CMS spreads it across strengths, so a box can differ: 4 Wegovy 2.4 mg pens are priced at $385.63.^13,14

$274 is the price drug plans and pharmacies work from, not your copay.¹³ What you pay still depends on your plan’s tier, deductible and the cap.^27,10 It doesn’t lift the weight-loss ban.³ The Bridge uses a separate $245 monthly net price agreed with the makers.¹ More in Ozempic’s $274 Medicare price: what you will actually pay.

Help with costs. With Extra Help, a plan can charge at most $12.65 for a brand-name drug in 2026, and $14.40 in 2027. Some people pay less.¹¹ You get Extra Help automatically with Medicaid, a Medicare Savings Program or SSI (Supplemental Security Income).¹⁰ The Medicare Prescription Payment Plan spreads your costs across the year, but it “doesn’t save you money”.¹⁰

What do the marks next to a GLP‑1 on a plan’s drug list mean?

They are the plan’s rules for that drug: prior authorization, step therapy or a quantity limit, and each one can be challenged with an exception.¹⁵

• Prior authorization (PA): approval you or your prescriber must get before the plan pays. Plans also use it when they cover a drug for some conditions but not others.¹⁵
• Step therapy (ST): you must try a cheaper drug on the list first.¹⁵
• Quantity limit (QL): a cap on how much the plan covers over a set time.¹⁵

A new plan may give you a transition fill. That is a one-time, 30-day supply of a drug you already take that the plan doesn’t cover, or covers only with PA or step therapy.¹⁵ From January 1, 2027, plans may process PA requests electronically.¹⁵ How to read the codes on any plan: reading your drug list and asking for an exception.

How do you ask a Part D plan to cover a GLP‑1?

You or your prescriber ask the plan for a coverage determination; a standard answer is due within 72 hours, and an urgent one within 24.¹⁶

A coverage determination is any plan decision about whether it pays for a drug, at what cost, and under which rules.¹⁶ You, your prescriber or your representative can ask by phone or in writing.¹⁶ Medicare offers a “Model Coverage Determination Request” form.¹⁸

An exception is a request to bend the plan’s rules. There are 2 kinds:¹⁷

• Formulary exception: cover a drug that isn’t on the list, or waive a PA, step therapy or quantity limit.
• Tiering exception: charge a non-preferred drug at a preferred tier’s cost.

Every exception needs a supporting statement from your prescriber. It must say the plan’s alternatives would work less well, cause harm, or both.^17,15 The 72-hour or 24-hour clock starts only when the plan gets that statement.¹⁶

An urgent (expedited) request is for when waiting could seriously harm your life, health or ability to regain function.¹⁸ An exception can’t open the weight-loss ban, because that use isn’t a covered Part D drug at all.³

What are the 5 levels of a Part D appeal?

If the plan says no, you have 65 days to ask it to look again; 4 more levels follow, each with a 60-day deadline.^18,19

1. 1Redetermination by your plan. Ask within 65 days of the date on the denial notice. The plan decides within 7 days, or 72 hours if urgent.^19,18
2. 2Independent Review Entity (IRE). An outside reviewer working for Medicare. Ask within 60 days of the plan’s decision; the same 7-day and 72-hour limits apply.^18,26
3. 3Office of Medicare Hearings and Appeals. An administrative law judge or attorney adjudicator. Ask within 60 days; in 2026 the amount at stake must be at least $200.^18,20
4. 4Medicare Appeals Council. Ask within 60 days of the hearing decision.¹⁸
5. 5Federal district court. Ask within 60 days of the Council’s decision; in 2026 the amount must be at least $1,960.^18,20

Each decision letter tells you how to go to the next level.¹⁸ If you miss a deadline, you must give a reason for filing late.¹⁸ Include your Medicare Number, the drug, why you disagree, and your prescriber’s statement.¹⁸

Bridge denials work differently. CMS tells prescribers who think a Bridge denial was wrong to resubmit the prior authorization for re-review.⁸ We found no separate appeal process described in CMS’s Bridge documents.^8,9,7 For employer, Marketplace and Medicaid plans, see how GLP‑1 appeals work and prior authorization, step by step.

What can you check during Medicare open enrollment?

From October 15 to December 7 you can switch drug or Advantage plans, and the new plan starts on January 1.²¹

This year that window runs October 15 to December 7, 2026, for coverage from January 1, 2027.²¹ The plan must get your request by December 7.²¹ In a Medicare Advantage plan, you get one more chance from January 1 to March 31: switch plans or return to Original Medicare.²¹

Medicare says to check that a plan covers your prescriptions.²¹ For a GLP‑1, look for these:

• Is your medicine on the plan’s list, and what is its copay or coinsurance?^4,10
• Does it carry PA, step therapy or a quantity limit?¹⁵
• What is the deductible? It can be up to $700 in 2027.¹⁰
• Is your pharmacy in the plan’s network, and what are the premium and the estimated yearly drug cost?²¹

The Bridge doesn’t depend on which plan you pick. You need to keep Part D, and some plan types are excluded, such as PACE (an all-in-one care program for frail older adults).⁷ Your State Health Insurance Assistance Program (SHIP) gives free, local help comparing plans.⁴ Step by step: how to check a Part D plan covers Ozempic, Wegovy or Zepbound.

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