Does health insurance cover drugs used for weight loss such as Ozempic, Wegovy, Mounjaro, and Zepbound?

Does health insurance cover drugs used for weight loss such as Ozempic, Wegovy, Mounjaro, and Zepbound?

It’s common for these drugs to be covered if they’re prescribed for another medical condition, such as diabetes, but not if they’re being used specifically for weight loss. But also, it very much depends on the type of health coverage you have.

What drugs are commonly prescribed for weight loss?

There are numerous glucagon-like peptide-1 receptor agonists (GLP-1 drugs) approved by the U.S. Food and Drug Administration (FDA) to treat type 2 diabetes.¹ But they have also proven to be effective in helping people lose weight, and three GLP-1 drugs – Wegovy, Zepbound, and Saxenda – have FDA approval to be used for chronic weight management.

Other GLP-1 drugs –such as Mounjaro, Ozempic, Trulicity, and Rybelsus – are approved for the treatment of type 2 diabetes, but not specifically for weight management.

Another medication, Orlistat (Xenical and over-the-counter Alli) is a lipase inhibitor – not a GLP-1 – and differs from the other medications in that it works for obesity management by preventing the absorption of fat in the gastrointestinal tract.²

If you’ve been diagnosed with type 2 diabetes, your doctor may prescribe a GLP-1. You’ll want to check with your health plan to see which GLP-1 drugs are covered, as health plans create their own formularies (covered drug lists) and do not have to cover all versions of a given category or class of drugs.

If you have cardiovascular disease along with either obesity or overweight, your doctor may prescribe Wegovy, as the FDA recently approved its use for helping reduce the risk of serious cardiovascular events in some patients.³ But again, you’ll want to check with your health plan to see if the medication is on the formulary.

If you have obesity or overweight – but not diabetes or cardiovascular disease – and your doctor wants to prescribe weight-loss medication, it’s less likely that your health plan will cover it, but it is possible.

Do Marketplace plans cover weight-loss drugs?

Under the Affordable Care Act (ACA), individual and small-group health plans are required to cover at least one drug in every United States Pharmacopeia (USP) category and class,⁴ or the same number of drugs in each category and class as the Essential Health Benefits (EHB) benchmark plan in the state.

However, CMS has clarified that the currently used USP guidelines do not include categories and classes of drugs “for anorexia, weight loss, or weight gain” and “these drugs are not required to be covered” under EHB rules.⁵ So coverage rules for medications prescribed specifically for weight loss (as opposed to treatment of another condition such as diabetes) are up to each state.

In a proposed rule published in late 2023,⁶ the Department of Health and Human Services solicited comments on whether they should consider switching EHB formulary coverage rules from USP MMG – which does not include a category for weight-loss drugs – to USP DC, which does.

Because this was only a request for comments and not a proposed rule change, no additional details about this were included in the final rule that was published in April 2024. But the agencies thanked commenters for their feedback and noted that they will “take these comments into consideration if we pursue potential updates for future benefit years.”

EHB benchmark plans are chosen and modified by each state. Most states’ requirements have not been updated since the 2017 plan year,⁷ when the benchmark plan was based on coverage that was sold in 2014 – before most of the modern weight-loss medications were approved for use.⁸

A 2022 Urban Institute analysis indicated that only North Carolina and New Mexico included coverage of weight-loss medications in the EHB benchmark plan.⁹ New Mexico’s coverage is new as of the 2022 plan year, and the updated plan includes coverage of weight-loss medications as part of “medically necessary treatment of morbid obesity and obesity.”¹⁰ North Dakota’s EHB benchmark plan will include coverage for weight-loss drugs, including GLP-1s for the treatment of morbid obesity, starting in 2025.¹¹

It should be noted that North Carolina’s EHB benchmark plan excludes “drugs indicated for the short-term treatment of clinical obesity.¹² However, the Urban Institute researchers included North Carolina as a state where the EHB benchmark plan covers pharmacology for weight loss because some anti-obesity medications (e.g. phentermine) can be prescribed for long-term.use ¹³ And since the North Carolina EHB benchmark plan doesn’t explicitly exclude all drugs used for weight loss, the Urban Institute analysis included it as an EHB benchmark plan that can provide coverage of some weight-loss medications.

However, according to HealthCare.gov’s plan comparison tool, there are no Marketplace plans in North Carolina that cover Wegovy, Saxenda, or Zepbound (the three GLP-1s approved for weight-loss). There are, however, Marketplace plans that cover phentermine.

The final rule published in April 2024 by HHS and the Department of the Treasury included changes designed to make it easier and less costly for states to update their EHB benchmark plans, including the addition of new benefits.¹⁴ The agencies pointed out¹⁵ that “commenters also noted that enabling States to more easily and, perhaps, therefore, more frequently, update their EHB-benchmark plans could result in expanded coverage for, among other things, maternity care, substance use disorder care, obesity care, and chronic disease management.”

So while most current EHB benchmark plans do not include coverage for anti-obesity medications, that could certainly change in the coming years.

Louisiana enacted legislation in 2024 that directs the state Department of Health to “evaluate bariatric surgery, pre-operative psychological screening and counseling, behavior modification, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary exercise, and lifestyle changes” to determine whether they should be included in the next update to the state’s EHB benchmark plan.¹⁶ But the legislation specifically notes that it does not require health plans to cover drugs to lower glucose or aid in weight loss.

Colorado lawmakers considered legislation in 2024 that would have required state-regulated health plans to cover FDA-approved medications to treat obesity. The bill passed in the Colorado Senate but did not pass in the House and was not enacted.¹⁷

It should also be noted that health plans are always free to offer coverage that goes above and beyond the EHB benchmark plan. A 2017 analysis found Silver-level Marketplace plans in nine states that included at least some coverage of pharmacotherapy for obesity.¹⁸ So consumers should always check with their plan to see what medications are covered, and carefully consider their coverage options during the annual open enrollment period.

Do employer-sponsored health plans cover weight-loss drugs?

Some employer-sponsored health plans cover weight-loss medications, even if the patient doesn’t have diabetes or cardiovascular disease. The specifics will depend partly on whether the plan is self-insured, or purchased by the employer in the large-group or small-group market.

Self-insured plans, which cover the majority of people with employer-sponsored health insurance,¹⁹ are designed by the employer and are regulated under ERISA, not state-level insurance laws or regulations. These plans vary considerably from one to another, and coverage of weight-loss drugs will depend on each specific employer’s approach.

For employers that purchase coverage in the large-group market or small-group market, the coverage options will depend on the plans that insurers make available to these employers. In the small-group market, plans have to provide at least the same benefits as the EHB benchmark plan. But as described above, most of those do not cover drugs used for weight loss.

While the majority of employer-sponsored health plans do cover GLP-1 drugs for the treatment of diabetes, only about a quarter do so for weight loss.²⁰ Although there is some expectation that more employers will start to provide weight-loss medication coverage,²¹ it’s worth noting that some employers are eliminating or restricting existing coverage of weight-loss drugs.²²

For example, the North Carolina State Employee Health Plan recently opted to stop covering GLP-1 agonist medications (such as Ozempic and Mounjaro) for members who do not have diabetes.²³ The plan had previously covered these drugs for weight loss, but noted that the cost was expected to grow to more than $1 billion by 2030, and roughly double the amount that enrolled members would have to pay in monthly premiums for their coverage.

Does Medicare cover drugs used for weight loss such as Ozempic and Wegovy?

Medicare does not cover these prescription drugs if they’re being used for weight loss rather than to treat another medical condition. Under federal law that dates back to the creation of Medicare Part D (see page 20489),²⁴ prescription drugs used for weight loss cannot be covered by Medicare Part D. Federal legislation would be necessary to change that rule.

However, Medicare Part D can cover medications such as Ozempic if they’re prescribed for other medical conditions, such as diabetes. These can include, as noted above, FDA-approved drugs like Wegovy – prescribed to reduce the risk of serious cardiovascular events in adults with cardiovascular disease along with obesity or overweight.²⁵

CMS reiterated that stance in a March 20, 2024 memo,²⁶ which clarified that Medicare Part D continues not to cover medications used for weight management. But the same medications can be covered by Medicare Part D if they “receive FDA approval for an additional medically accepted indication” and are prescribed for non-obesity conditions, such as diabetes.

Across three GLP-1 drugs approved to treat diabetes, total Medicare Part D spending was 100 times higher in 2022 than it had been in 2018.²⁷

Does Medicaid cover drugs used for weight loss such as Ozempic and Wegovy?

Under federal Medicaid drug coverage rules,²⁸ states can exclude coverage of weight-loss drugs. But while federal Medicare Part D rules expressly prohibit coverage of weight-loss drugs, the Medicaid rules leave that decision up to each state.

According to a 2022 Urban Institute analysis, fee-for-service Medicaid only covers weight-loss medication in 15 states, and only four other states cover weight-loss medications under at least one Medicaid managed-care plan.²⁹ (Most people with Medicaid are enrolled in managed care plans, rather than fee-for-service Medicaid.)³⁰

Again, as with the categories described above, coverage of a drug for weight loss is different from coverage of the same drug to treat diabetes or reduce cardiovascular risk. So Medicaid coverage of weight-loss drugs will depend on the reason why the drug is being prescribed, as well as the state where the person lives and whether their coverage is administered by the state (fee-for-service) or by an insurance company (Medicaid managed care).

How much do weight-loss drugs cost?

The U.S. list prices for some of the most common medications used for weight loss range from more than $900/month to more than $1,300/month.³¹ It’s easy to see how this can be out of reach for many people without insurance coverage, although many of the manufacturers offer coupons that can reduce the monthly cost.

If a health plan does cover these medications – either to treat diabetes, lower cardiovascular risk, or treat obesity – the out-of-pocket costs will vary by plan. They will depend on the formulary tier the plan uses for that medication, whether the out-of-pocket cost is a copay (flat amount) or coinsurance (percentage of the total cost), and whether the plan has a separate deductible for prescriptions.

If the specific medication your doctor recommends is not on your health plan’s formulary, you and your doctor can file an appeal, asking the plan to cover the drug anyway. If the plan denies the request but has other similar medications on its formulary, you can have a discussion with your doctor about whether one of the covered drugs might work for you.