Medicare began covering Wegovy and Zepbound for some enrollees after a landmark policy shift in 2024, but coverage in 2026 still depends on why a drug is prescribed. If your plan covers the medication and you qualify, the new $2,000 annual out-of-pocket cap under the Inflation Reduction Act can meaningfully limit what you spend each year.
What Changed That Allowed Medicare to Cover These Drugs?
For decades, a federal statute called the Exclusion Clause barred Medicare Part D plans from covering drugs approved solely for weight loss. That restriction still technically exists. However, the FDA's 2021 approval of Wegovy (semaglutide) and 2023 approval of Zepbound (tirzepatide) created a new legal pathway. Both drugs carry additional FDA-approved indications beyond weight management:
- Wegovy: Approved in March 2024 to reduce the risk of serious cardiovascular events (heart attack, stroke, cardiovascular death) in adults with obesity or overweight who also have established cardiovascular disease — based on the SELECT trial published in the New England Journal of Medicine in 2023.
- Zepbound: Approved in June 2024 for obstructive sleep apnea (OSA) in adults with obesity, and carries a cardiovascular risk-reduction indication as well.
In January 2025, the Centers for Medicare & Medicaid Services (CMS) confirmed that Part D plans may cover these drugs when prescribed for an FDA-approved non-weight-loss indication such as cardiovascular risk reduction or OSA. Coverage is not automatic or universal — individual Part D and Medicare Advantage plans set their own formularies.
Most important point: Medicare coverage of Wegovy or Zepbound in 2026 is tied to your diagnosis, not just your weight. Prescribing for cardiovascular risk reduction or obstructive sleep apnea is the primary path to coverage. Weight loss alone remains excluded under federal law.
Does Your Specific Medicare Plan Actually Cover It?
Even if you have a qualifying diagnosis, coverage varies widely by plan. Here is what to check:
- Part D standalone plans: Review the plan's formulary (drug list). Wegovy and Zepbound are typically placed on higher tiers (Tier 4 or 5), meaning cost-sharing is significant even when covered.
- Medicare Advantage (Part C): Many Medicare Advantage plans added Wegovy and Zepbound to their formularies in 2025 and 2026 for cardiovascular and OSA indications. Call your plan directly or use Medicare's Plan Finder tool.
- Prior authorization: Nearly all plans that cover these drugs require prior authorization documenting the qualifying diagnosis, BMI criteria, and often a failed trial of lifestyle intervention.
- Step therapy: Some plans require you to try a lower-cost drug first before approving a GLP-1.
What Will You Pay Out of Pocket in 2026?
The Inflation Reduction Act's $2,000 annual out-of-pocket cap on Part D drugs took effect January 1, 2025, and continues in 2026. This is a significant change from prior years, when catastrophic costs could exceed $5,000. Here is how costs break down under typical coverage scenarios:
| Coverage Scenario | Estimated Monthly Cost | Annual Cap Applies? |
|---|---|---|
| Part D covers Wegovy/Zepbound (qualifying diagnosis) | $200–$600 until cap is met | Yes — $2,000 max out of pocket |
| No Part D coverage; using manufacturer savings card (not Medicare-eligible) | Not applicable — savings cards cannot be used with Medicare | No |
| Low-Income Subsidy (Extra Help) enrollee | Minimal copay, often $0–$11 | Yes, with further reductions |
| Medicare Advantage plan covering drug | Varies by plan; often Tier 4 cost-sharing | Yes — $2,000 MOOP applies |
| No qualifying diagnosis; drug not covered | $1,000–$1,350/month (list price) | No |
Important: Manufacturer copay assistance cards (such as Novo Nordisk's Wegovy savings card or Eli Lilly's Zepbound savings card) are not legal to use with Medicare. Using them can violate federal anti-kickback statutes and may put your coverage at risk.
Can Medicare Part B Ever Cover These Drugs?
Medicare Part B covers drugs that are administered in a clinical setting, such as infusions. Since Wegovy and Zepbound are self-injected at home, they are not covered under Part B. Coverage, when available, falls entirely under Part D or a Medicare Advantage drug benefit.
Is Medicare Coverage Expected to Expand in 2026?
Advocates and many policymakers have pushed for broader Medicare coverage of anti-obesity medications, but as of early 2026, no legislation has passed that would remove the statutory exclusion for weight-loss-only indications. The Treat and Reduce Obesity Act (TROA), which would have explicitly allowed Part D to cover FDA-approved obesity drugs, has been reintroduced multiple congressional sessions without passing. CMS has signaled openness to expanded access but has not issued a final rule removing the exclusion. For most Medicare enrollees, a cardiovascular disease or OSA diagnosis remains the clearest path to coverage in 2026.
Frequently Asked Questions
Medicare coverage of Wegovy and Zepbound is evolving quickly, and plan-level details change every year during open enrollment. Talk with your prescribing clinician about which FDA-approved indication best fits your health history, and work with your Medicare plan or a SHIP counselor to confirm whether your specific policy covers the drug before filling your first prescription.
- Centers for Medicare & Medicaid Services, "Medicare Part D Coverage of Anti-Obesity Medications", CMS.gov, 2025
- Lincoff A.M. et al., "Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes (SELECT Trial)", New England Journal of Medicine, 2023
- FDA, "Zepbound (tirzepatide) Prescribing Information", U.S. Food and Drug Administration, 2023
- FDA, "Wegovy (semaglutide) Prescribing Information", U.S. Food and Drug Administration, 2021
- KFF, "Medicare Coverage of Obesity Drugs: What to Know", Kaiser Family Foundation, 2025