Table of Contents
Introduction
Medicare is a health insurance program run by the United States government. It provides coverage for people age 65 and older, and for some younger people with disabilities. One part of Medicare, known as Part D, helps pay for prescription drugs. This coverage plays an important role in making sure people can get the medicines they need at a price they can afford. However, not every drug is covered, and even when it is, the coverage rules can be complicated. That’s why there are so many questions about new drugs like tirzepatide and whether Medicare will pay for them.
Tirzepatide is a new kind of medicine that is getting a lot of attention. It is sold under the brand names Mounjaro and Zepbound. Mounjaro is approved by the U.S. Food and Drug Administration (FDA) to treat type 2 diabetes. Zepbound is approved to help with weight loss in people who have obesity or who are overweight and have at least one weight-related condition. In 2024, the FDA also approved tirzepatide for people with obstructive sleep apnea, a sleep disorder that causes breathing to stop and start during sleep.
Tirzepatide works in a new way compared to older drugs. It affects two hormones in the body that help control blood sugar and appetite. These hormones are called GIP and GLP-1. Because it works on both, tirzepatide is called a “dual agonist.” This means it activates both of these natural hormones. This new approach seems to help some people lose more weight and control their diabetes better than with older medicines. That has led to high demand for the drug, but also high interest in how it will be paid for, especially by Medicare.
The price of tirzepatide is high. Without insurance, the monthly cost can be more than $1,000. This has raised questions among patients, doctors, and insurance providers. People want to know if Medicare will help pay for this drug, and if so, under what conditions. Because many older adults are on fixed incomes, Medicare coverage is often the only way they can afford expensive prescription drugs.
Right now, Medicare does pay for Mounjaro when it is prescribed to treat type 2 diabetes. But things are more complicated when tirzepatide is used for weight loss or for sleep apnea. That’s because Medicare has rules that block coverage for drugs that are only meant for weight loss. These rules come from a law passed in 2003 called the Medicare Modernization Act. That law created Medicare Part D but also said Medicare cannot pay for drugs used to treat obesity.
This rule has become more controversial in recent years. Many doctors and health experts now view obesity as a serious medical condition that can lead to many other problems, like heart disease and diabetes. Some lawmakers and groups are pushing for Medicare to change this rule and start covering weight-loss drugs, especially ones like tirzepatide that have shown strong results in clinical trials. There is growing interest in how drugs like tirzepatide could save Medicare money in the long run by helping people avoid hospital stays or other treatments caused by weight-related conditions.
Tirzepatide’s approval for treating sleep apnea may change things. Sleep apnea is a medical condition that Medicare already covers, and tirzepatide may now be paid for when used for this reason. Still, coverage depends on many details, including how a Medicare plan is set up, what the drug is prescribed for, and whether the patient meets certain conditions. That means not everyone will get the same level of coverage.
The future of Medicare coverage for tirzepatide is an important topic because it affects access to care, drug costs, and health outcomes. There are many questions about how the drug is covered now, how much it costs under different plans, and whether new laws or policies could change things in the future. Understanding these issues can help people make better choices and know what to expect. The sections that follow explain how Medicare coverage works for tirzepatide, what patients should know about costs and restrictions, and what changes may be coming.
What Is Tirzepatide and What Conditions Is It FDA-Approved to Treat?
Tirzepatide is a prescription medication that helps lower blood sugar and reduce body weight. It belongs to a group of drugs called incretin mimetics. Tirzepatide acts on two hormones at the same time—GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 (glucagon-like peptide-1). These hormones are naturally made in the body and help with blood sugar control, digestion, and feeling full after eating. By copying the effects of both, tirzepatide works more powerfully than drugs that target GLP-1 alone.
Tirzepatide is taken once a week as an injection under the skin. It is sold under two brand names in the United States: Mounjaro and Zepbound. Each brand is approved by the U.S. Food and Drug Administration (FDA) for a specific condition.
Tirzepatide as Mounjaro – Approved for Type 2 Diabetes
The first approval came in May 2022, when the FDA approved tirzepatide as Mounjaro. This approval was for adults with type 2 diabetes. Mounjaro is meant to improve blood sugar control in people whose diabetes is not well managed by lifestyle changes or other medications.
Tirzepatide helps in several ways. It increases insulin release from the pancreas when blood sugar levels are high. It also lowers the amount of sugar made by the liver. In addition, it slows down how fast the stomach empties food, which helps control appetite and leads to weight loss. This combined effect makes tirzepatide highly effective.
Studies show that people taking Mounjaro had major improvements in their blood sugar levels. Many reached their target A1C level, a measure that reflects average blood sugar over several months. The drug also helped many patients lose weight, even though it was not officially approved for weight loss at the time. However, because the approval was only for diabetes, insurance coverage—including Medicare—is generally limited to that use.
Some doctors may prescribe Mounjaro “off-label” for weight loss, but Medicare and most other insurance providers do not pay for the drug when used this way. That’s because Medicare only covers drugs for uses that are approved by the FDA or backed by strong medical guidelines.
Tirzepatide as Zepbound – Approved for Weight Loss
In November 2023, tirzepatide received FDA approval under a new brand name—Zepbound—for use in chronic weight management. This approval is for adults who either have obesity or are overweight with at least one weight-related condition. This includes problems like high blood pressure, high cholesterol, or type 2 diabetes.
Zepbound is meant to be used along with a low-calorie diet and increased physical activity. It is not a replacement for healthy habits but is designed to support them. Clinical trials showed that people taking Zepbound lost a large amount of weight. On average, people lost more than 15 percent of their body weight, and some lost over 20 percent.
This kind of weight loss can have major health benefits. It can lower the risk of heart disease, improve blood pressure and blood sugar, reduce joint pain, and improve overall quality of life. However, Medicare does not cover Zepbound when it is used only for weight loss. This is because of a federal rule that blocks Medicare from paying for weight loss medications, even when they are FDA-approved.
Zepbound – Approved for Obstructive Sleep Apnea
In December 2024, the FDA approved another use for Zepbound. It is now approved to treat obstructive sleep apnea (OSA) in adults with obesity. OSA is a condition where breathing stops and starts during sleep. It can lead to problems such as fatigue, heart disease, and high blood pressure.
In people with OSA who are also obese, losing weight can help reduce the number of breathing interruptions during the night. Clinical studies showed that people who took Zepbound had fewer breathing problems and better sleep quality. This led the FDA to approve Zepbound for treating sleep apnea in these patients.
This new approval may allow for wider insurance coverage in the future. Medicare may consider covering Zepbound for sleep apnea, even though it still excludes weight loss treatments. The key difference is that the drug would be treating a medical condition, not just helping with weight loss alone.
Tirzepatide is approved by the FDA for three different medical conditions. The first is type 2 diabetes, for which it is sold as Mounjaro. The second is weight management in people with obesity or overweight with health risks, for which it is sold as Zepbound. The third is obstructive sleep apnea in people with obesity, which was added as a new use for Zepbound. Each approval opens the door to different patients and may affect insurance coverage, including what Medicare may or may not pay for.
Does Medicare Currently Cover Tirzepatide?
Tirzepatide is a newer medication used to treat type 2 diabetes. It is sold under the brand name Mounjaro. Another version called Zepbound is approved for weight loss. Medicare coverage depends on why the drug is prescribed and which Medicare plan a person has.
Coverage for Type 2 Diabetes
As of mid-2025, Medicare does cover tirzepatide when it is prescribed to treat type 2 diabetes. This coverage is offered through Medicare Part D, which is the part of Medicare that helps pay for prescription drugs. Mounjaro is the brand-name version of tirzepatide used for diabetes. According to drug coverage data, about 91% of Medicare Part D plans include Mounjaro on their list of covered drugs, also called a formulary.
Coverage under Part D can vary between insurance companies. Medicare allows private insurers to offer Part D plans. Each plan has its own formulary, and not all plans cover every drug. Even though most plans cover Mounjaro, some may not. Also, plans may place the drug on different tiers, which affects how much a patient pays out of pocket.
In many plans, Mounjaro is listed as a Tier 3 drug. This tier usually includes non-preferred brand-name drugs and comes with higher copays or coinsurance than lower tiers. Depending on the plan, patients may pay a flat fee, like $45, or a percentage of the drug’s cost. During the coverage gap or “donut hole” phase, out-of-pocket costs may be much higher. These costs can range from hundreds to over a thousand dollars for a one-month supply.
Coverage for Weight Loss
Medicare does not cover tirzepatide when it is prescribed only for weight loss. The brand name for this use is Zepbound. Even though the U.S. Food and Drug Administration (FDA) has approved Zepbound for chronic weight management, Medicare does not include it in the list of allowed drug uses for coverage.
This is because of a rule in the law that created Medicare’s drug benefit, called the Medicare Modernization Act of 2003. This law says that Medicare cannot cover medications that are used only to treat obesity or weight problems. Because of this rule, drugs like Zepbound, Wegovy, and Saxenda are not included in Medicare Part D or Medicare Advantage drug plans when prescribed for weight loss.
Some groups have asked Congress to change this rule so that Medicare can cover anti-obesity medications. These efforts have not yet led to a change in the law. As a result, people on Medicare who want to use tirzepatide for weight loss must pay the full cost of the drug out of pocket unless they have other insurance that provides coverage.
Coverage and Medicare Plan Type
People with Original Medicare (Parts A and B) do not get drug coverage unless they enroll in a separate Part D plan. Those with Medicare Advantage plans that include drug coverage (Part C with drug benefits) may also get access to Mounjaro for diabetes, depending on the plan’s formulary.
People who qualify for Medicare and Medicaid (called “dual eligible”) may have more help paying for tirzepatide when it is prescribed for diabetes. Medicaid may offer additional drug coverage in some states. However, these benefits still do not apply to weight loss uses because of the same Medicare law.
Medicare currently covers tirzepatide only when it is used to treat type 2 diabetes. Mounjaro, the version used for diabetes, is included in most Part D plans, but coverage details and costs vary. Tirzepatide is not covered when used for weight loss under the brand Zepbound due to federal law. People who are interested in this medication should check their Medicare drug plan to see how it is covered and what the out-of-pocket costs might be.
How Tirzepatide Coverage Works Across Medicare Plan Types
Tirzepatide is a prescription medication that is used to treat type 2 diabetes, obesity, and more recently, obstructive sleep apnea (OSA). How this medication is covered depends on the type of Medicare plan a person has. Medicare is a federal health insurance program that covers millions of older adults and people with certain disabilities. However, Medicare is divided into different parts, and not all of them include drug coverage.
There are four main parts of Medicare: Part A, Part B, Part C (also called Medicare Advantage), and Part D. Each part has a different role in helping people pay for healthcare.
Original Medicare and Drug Coverage
Original Medicare includes Part A and Part B. Part A covers hospital stays, nursing facility care, hospice, and some home health services. Part B covers outpatient care like doctor visits, lab tests, and preventive services. However, Original Medicare does not include prescription drug coverage. This means that people who only have Part A and Part B will not get help paying for tirzepatide unless they also enroll in a separate drug plan, known as Medicare Part D.
Some drugs are covered under Part B if they are given in a doctor’s office or hospital outpatient setting. These drugs are usually injected or infused. Tirzepatide, which is given by injection under the skin and taken at home, is not typically covered under Part B. It falls under Medicare Part D instead, because it is self-administered.
Medicare Part D and Tirzepatide
Medicare Part D is a separate drug plan that helps cover the cost of prescription medications. People can buy Part D plans through private insurance companies approved by Medicare. These plans have different costs and lists of covered drugs, called formularies.
Tirzepatide is covered under many Medicare Part D plans when it is prescribed to treat type 2 diabetes. For this use, it is sold under the brand name Mounjaro. Each plan may place Mounjaro in a different “tier.” A tier is a category that determines how much a person has to pay. Lower tiers usually have lower out-of-pocket costs, while higher tiers cost more. Mounjaro is usually placed in Tier 3 or higher, meaning it is considered a non-preferred brand drug and may have higher copays or coinsurance.
Zepbound, the brand name for tirzepatide approved for weight management, is not covered under Part D unless it is prescribed for another approved condition like obstructive sleep apnea. Medicare rules currently exclude coverage of drugs that are only used for weight loss. This makes it harder for people to get help paying for Zepbound unless new laws are passed or Medicare changes its policy.
Medicare Advantage Plans and Drug Coverage
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. These plans are offered by private insurance companies and combine Part A, Part B, and often Part D into one plan. Medicare Advantage plans must cover everything Original Medicare covers and often include extra benefits like vision, hearing, and dental care.
Most Medicare Advantage plans include prescription drug coverage. This means that tirzepatide can be covered under these plans if it is prescribed for an approved use, such as type 2 diabetes. The rules about which drugs are covered and how much they cost depend on the plan. Just like with Part D, each Medicare Advantage plan has a formulary and may use drug tiers. Prior authorization or other rules may also apply. A doctor may need to explain why the medication is medically necessary before the plan agrees to cover it.
Plan Formularies and Variability
It is important to note that not all Medicare drug plans are the same. Some plans may cover tirzepatide for certain conditions, while others may not. One plan might have lower costs or fewer restrictions than another. This can make it confusing for patients trying to understand their options. During the Medicare Open Enrollment Period, people have a chance to compare plans and switch to one that better fits their medication needs.
People who want Medicare to help pay for tirzepatide need to be enrolled in either a standalone Medicare Part D plan or a Medicare Advantage plan that includes drug coverage. Original Medicare alone does not include prescription drugs. Coverage can vary widely depending on the plan, the specific use of tirzepatide, and whether the drug is listed on the plan’s formulary. It is important to check each plan’s drug list, tier structure, and rules to understand what is covered and how much it will cost.
What Costs and Cost-Sharing Can Beneficiaries Expect Under Medicare?
Tirzepatide is a medication used to treat type 2 diabetes and, more recently, obesity and sleep apnea. It is sold under brand names like Mounjaro and Zepbound. For people with Medicare, understanding how much this medication costs is important. Even when a drug is covered, there are different stages of cost-sharing. These include the deductible, initial coverage, the coverage gap (also known as the “donut hole”), and the catastrophic coverage phase. Each stage has different rules about how much must be paid out of pocket.
Deductible Stage
Most Medicare Part D plans have a yearly deductible. In 2025, this amount can be up to $590. Until this amount is paid out of pocket, the plan does not cover the cost of prescription drugs. If someone is prescribed tirzepatide and they have not met their deductible yet, they may need to pay the full cost of the drug until they reach that limit. The retail cost of tirzepatide can be more than $1,000 per month without insurance, so this can be a large upfront cost.
Initial Coverage Phase
After meeting the deductible, the person enters the initial coverage phase. In this stage, Medicare and the plan begin to share the cost of covered drugs. The beneficiary usually pays a copayment or coinsurance. Most Part D plans place tirzepatide in a Tier 3 or Tier 4 category, which are considered non-preferred brand-name drugs.
The copay or coinsurance for a Tier 3 or Tier 4 drug is higher than for generic drugs. For example, people might pay $45 to $150 for a one-month supply during this stage, depending on the specific plan. In some cases, the cost could be even higher if the plan uses coinsurance, which is a percentage of the total drug cost. A 25% coinsurance on a $1,000 drug would mean a $250 out-of-pocket payment.
Coverage Gap (“Donut Hole”)
Once total drug costs (what the plan and the person have paid together) reach a certain amount—$5,030 in 2025—the person enters the coverage gap. In this stage, beneficiaries pay 25% of the cost of their brand-name drugs, including tirzepatide.
For example, if the monthly cost of tirzepatide is $1,050, the person would pay about $262.50 out of pocket each month in the gap. This phase continues until out-of-pocket spending reaches the catastrophic coverage threshold, which is $8,000 in 2025. These costs include the deductible, coinsurance, copays, and discounts received in the coverage gap.
Catastrophic Coverage
After reaching the $8,000 spending limit, the catastrophic coverage phase begins. Starting in 2025, due to the Inflation Reduction Act, beneficiaries will no longer pay coinsurance or copays during this phase. This change is new and will help many people who take expensive medications like tirzepatide.
Before this law, people still had to pay 5% of drug costs during catastrophic coverage, which could still be high. Now, Medicare and the plan pay the full cost after the person reaches the cap. This makes high-cost medications much more affordable for people who need them long-term.
Summary of Monthly Costs
Costs can vary a lot depending on the plan, the drug’s tier, and the stage of coverage. On average:
- During the deductible: pay full cost (up to $1,000+ per month)
- Initial coverage: copay of $45 to $150, or coinsurance (up to 25%)
- Coverage gap: pay 25% of the drug’s cost
- Catastrophic phase: pay $0 after reaching $8,000 out of pocket
These amounts also depend on which version of tirzepatide is being used. Mounjaro is usually covered for type 2 diabetes. Zepbound, for weight loss, is often not covered by Medicare unless prescribed for sleep apnea, depending on the plan.
Importance of Plan Comparison
Each Medicare Part D plan has a formulary, or list of covered drugs. Tirzepatide may be included on most formularies, but placement on higher tiers makes it more expensive. It is important to check the formulary tier, monthly premium, and out-of-pocket limits of each plan before enrolling or renewing coverage. Comparing plans each year during open enrollment can help lower costs for expensive drugs like tirzepatide.
Understanding these four stages of Medicare Part D helps explain why the same drug can cost different amounts for different people and at different times of the year. It also shows why planning ahead and choosing the right plan is key to managing the high cost of this medication.
Are There Utilization Barriers—Prior Authorization and Quantity Limits?
Tirzepatide, sold under brand names like Mounjaro for type 2 diabetes and Zepbound for weight loss, is a newer medication. Because of its high cost and powerful effects, many Medicare drug plans place controls on how and when it can be used. These controls are known as utilization management tools, and they are commonly used for expensive or specialty medications. The two most common tools used by Medicare Part D and Medicare Advantage plans are prior authorization and quantity limits.
What Is Prior Authorization?
Prior authorization means that a healthcare provider must get special approval from the insurance plan before the patient can get the drug. The goal is to make sure the drug is medically necessary and used for an approved condition.
For tirzepatide, most Medicare plans require prior authorization before they will cover it. According to drug formulary data from Medicare plans, this requirement applies to both Mounjaro (for type 2 diabetes) and Zepbound (for weight loss or obesity-related conditions).
Plans often want proof that:
- The patient has a diagnosis that matches the FDA-approved use (e.g., type 2 diabetes for Mounjaro).
- The drug is being used according to medical guidelines.
- The patient has tried other treatments first, such as metformin or other GLP-1 drugs like semaglutide, and those have not worked well enough.
This means the prescriber needs to send the insurance plan clinical notes or other documents. If the plan does not approve the request, it will not pay for the drug.
Why Do Plans Use Prior Authorization?
Prior authorization helps Medicare plans control costs and reduce misuse. Tirzepatide is a high-cost medication, and there is growing demand for it beyond diabetes. Many patients want it for weight loss alone. However, current Medicare law does not allow coverage of drugs used only for obesity, unless the patient has another approved medical condition.
Because of this, plans are especially strict about checking the diagnosis and making sure the drug is not being used for a non-covered reason. For example, if a doctor prescribes Zepbound for general weight loss without a related condition like obstructive sleep apnea or cardiovascular disease, the plan will likely deny coverage.
What Are Quantity Limits?
In addition to prior authorization, most Medicare drug plans place quantity limits on tirzepatide. This means they only allow a certain amount of the medication to be dispensed at one time—usually one injection per week.
For example, a plan may approve only four doses per month. If a prescriber tries to order more than that, the pharmacy system will reject the claim unless there is a separate approval.
Quantity limits help ensure:
- Safe use of the medication
- No early refills or overuse
- Proper dosing that follows guidelines
Tirzepatide is a once-weekly injectable medication. Allowing more than the recommended amount could raise the risk of side effects such as nausea, vomiting, or low blood sugar, especially when combined with other medications.
Plans may also limit how quickly the dose can be increased. Tirzepatide dosing usually starts low and increases gradually. Some plans will not allow the patient to jump to a higher dose without showing that they have tolerated lower doses first. This step-by-step approach is meant to protect the patient’s safety.
Can Exceptions Be Made?
Sometimes, a plan may make an exception. If a doctor believes the patient truly needs more medication or faster access to a higher dose, they can file a coverage determination request. This asks the insurance plan to approve an exception to its rules. The plan must respond quickly, often within 72 hours for a standard request or 24 hours if the situation is urgent.
However, approval is not guaranteed. The plan will still want detailed medical information to support the request. The process can be time-consuming, and patients may need to wait before starting or continuing treatment.
To get tirzepatide covered under Medicare Part D or a Medicare Advantage plan, most people will need prior authorization. Their doctor must prove the medication is being used for an approved condition. Patients will also face quantity limits that control how much medication they can receive and how often. These barriers are in place to reduce misuse, ensure safety, and manage costs—but they can also delay access to care for those who qualify.
Is Tirzepatide Covered When Prescribed for Non-Diabetes Uses (Weight Loss, Obstructive Sleep Apnea)?
Tirzepatide is approved by the U.S. Food and Drug Administration (FDA) for more than one health condition. Originally, it was approved to help control blood sugar in adults with type 2 diabetes. That version is sold under the brand name Mounjaro. Later, the same drug was approved to help with weight loss and obesity. That version is called Zepbound. Most recently, tirzepatide was also approved to treat obstructive sleep apnea (OSA) in people who also have obesity. These different uses affect how and whether the drug is covered by Medicare, which is the federal health insurance program for people age 65 and older, and for some younger people with disabilities.
Weight Loss Use Is Not Covered by Medicare
Medicare does not currently cover any drugs that are used only for weight loss, including Zepbound. This is because of a law passed in 2003 called the Medicare Modernization Act (MMA). That law created Medicare Part D, which is the part of Medicare that covers prescription drugs. However, it specifically blocks Medicare from covering medicines used only to treat obesity, even if they are FDA-approved.
The Centers for Medicare & Medicaid Services (CMS), the agency that manages Medicare, has stated that weight loss medications are considered lifestyle treatments, not medically necessary drugs, under current law. Because of that, tirzepatide is not covered by Medicare when it is prescribed only for weight loss. This applies even when the person has obesity, or even if the drug is proven to improve weight-related health problems.
Zepbound’s official approval is for chronic weight management in adults with obesity (or those who are overweight and have at least one weight-related condition like high blood pressure or high cholesterol). Despite its health benefits, it is not covered under Medicare unless it is prescribed for another covered condition, such as diabetes or potentially sleep apnea.
Obstructive Sleep Apnea: A New FDA-Approved Use
In June 2024, tirzepatide (Zepbound) was approved by the FDA to treat obstructive sleep apnea (OSA) in adults who are overweight or have obesity. OSA is a serious health condition where a person’s breathing stops and starts during sleep. It increases the risk for heart disease, stroke, diabetes, and high blood pressure. People with OSA often use machines like CPAP (Continuous Positive Airway Pressure) to help them breathe at night. However, many people do not tolerate these machines well or do not get enough relief from them.
Tirzepatide’s approval for OSA is based on studies showing that the drug helps reduce the number of breathing interruptions during sleep and improves oxygen levels in the blood. These benefits were seen especially in people with obesity, which is a major risk factor for sleep apnea. Because of these improvements, the FDA approved Zepbound for use in patients with moderate-to-severe OSA and a high body mass index (BMI), even if they do not have diabetes.
Will Medicare Cover Tirzepatide for Sleep Apnea?
The approval for treating sleep apnea has opened the door to possible Medicare coverage, but it is not guaranteed. Medicare coverage for any drug depends on whether the drug is prescribed for a covered medical condition, and whether the drug is on the plan’s formulary (the list of drugs that a Medicare plan pays for). In this case, OSA is a covered medical condition under Medicare, so that helps. However, each Part D or Medicare Advantage plan makes its own decisions about which drugs to cover and under what rules.
Some Medicare Advantage plans may choose to add Zepbound for sleep apnea to their formularies, especially if more data shows long-term savings or improvements in health outcomes. However, as of mid-2025, many plans have not yet updated their drug lists to include Zepbound for OSA. It may still require prior authorization, meaning doctors must show medical proof that the drug is needed and that other treatments did not work. There may also be quantity limits or step therapy requirements.
Medicare does not cover tirzepatide for weight loss alone because of a federal law that excludes anti-obesity medications. This applies even when weight loss would clearly improve health. However, the situation is different for sleep apnea. Because obstructive sleep apnea is a covered condition, and tirzepatide is now FDA-approved to treat it, some Medicare plans may start to cover Zepbound for this use. Whether it is covered depends on the plan’s drug list and approval process. Beneficiaries and health providers should check with the specific Medicare plan to find out if coverage is available for sleep apnea treatment with tirzepatide.
What Policy Changes Are on the Horizon?
Tirzepatide, sold under the brand names Mounjaro and Zepbound, is an important new drug that treats type 2 diabetes, obesity, and now obstructive sleep apnea (OSA). While it is covered by Medicare when used for type 2 diabetes, it is not currently covered when used for weight loss alone. Many people are asking if Medicare will start covering this drug for weight loss or other uses in the near future. Understanding how Medicare makes these decisions and what changes may be coming helps explain the future of drug access.
Current Law Blocks Coverage for Weight Loss Drugs
The main reason Medicare does not cover drugs like Zepbound for weight loss is because of a federal law from 2003. This law, known as the Medicare Modernization Act, created Medicare Part D to cover prescription drugs. But it also added a rule that says weight loss drugs cannot be covered. The law includes them in a group of “excluded drugs,” along with cosmetic treatments and certain over-the-counter products.
Even though Zepbound has been approved by the Food and Drug Administration (FDA) for chronic weight management, the Medicare rules still apply. That means Medicare cannot cover it unless the law is changed. Some members of Congress and many doctors and patient groups have called for updates to this law. They argue that weight loss drugs are no longer just for appearance. Instead, they treat real medical conditions like obesity, heart disease, and sleep apnea.
New Policy Proposals Could Expand Coverage
There has been recent movement at the federal level to change Medicare’s position. In late 2023, the Centers for Medicare & Medicaid Services (CMS) asked for public comments on whether anti-obesity drugs should be covered under Part D. The goal was to gather input from doctors, patients, drug companies, and insurance plans. Many believed this was the first step toward allowing Medicare to cover weight loss medications like tirzepatide.
At the time, experts believed the new rules could go into effect as early as 2026. This would have been a major change for Medicare, allowing millions of older adults to receive coverage for modern obesity treatments. Many people with Medicare also have related conditions like high blood pressure, type 2 diabetes, and heart disease. Treating obesity could help manage or prevent these illnesses, which may lower long-term health care costs.
CMS Withdraws Coverage Expansion Plan
However, in April 2025, CMS announced it would not move forward with its plan to expand coverage for anti-obesity drugs. This decision surprised many people, especially because of the strong public support for change. CMS said that the current legal limits still apply, and the agency does not have the power to go beyond them without new laws passed by Congress.
This means that, for now, Medicare will not cover tirzepatide when prescribed only for weight loss. It will continue to cover the drug when it is used to treat type 2 diabetes. It may also be covered in certain cases when used for sleep apnea, depending on the specific Medicare plan and medical need.
Congress May Still Act
Although CMS paused its efforts, Congress may still take steps to change the law. Several bills have been introduced in recent years to allow Medicare to cover anti-obesity medications. One of the most well-known is the Treat and Reduce Obesity Act. This bill has been introduced multiple times since 2013. It would change Medicare rules to cover both prescription drugs for obesity and other treatments like diet counseling and exercise programs.
So far, the bill has not passed into law. But it has gained support from lawmakers in both major political parties, which is rare in health care policy. The growing number of Americans with obesity, along with new medications like tirzepatide, has increased pressure on Congress to act.
Future Coverage Still Uncertain
The future of Medicare coverage for tirzepatide used for weight loss remains uncertain. On one hand, there is growing scientific evidence that these drugs are effective and can reduce the risks of heart disease, diabetes, and sleep apnea. On the other hand, the cost of these medications is very high. Some experts estimate that covering anti-obesity drugs under Medicare could cost more than $35 billion over ten years. Lawmakers will have to weigh the cost of expanded coverage against the long-term savings from better health outcomes.
Until Congress changes the law, Medicare will only cover tirzepatide when used for conditions that are already allowed, like diabetes. Patients, doctors, and advocacy groups will likely continue pushing for coverage to expand, but real change will depend on future policy decisions at the federal level.
Why Is Coverage Expansion Controversial?
Medicare coverage for new drugs often takes time and debate. Tirzepatide, especially when used for weight loss or conditions like obstructive sleep apnea (OSA), is at the center of a national conversation. The drug works well and helps people lose weight or manage serious health problems. However, there are many concerns about how much it costs, who should pay for it, and whether it should be part of Medicare’s drug list. Several key issues make the idea of expanding Medicare coverage for tirzepatide complicated and sometimes controversial.
High Cost to Medicare
One of the biggest concerns is the high cost of tirzepatide. The list price for a monthly supply can be more than $1,000 without insurance. Even when insurance helps cover the cost, Medicare would still have to pay a large portion of the drug price through its Part D plans or Medicare Advantage plans.
Experts have estimated that covering weight-loss drugs like tirzepatide under Medicare could cost over $35 billion in the next 10 years. That number could go even higher as more people become eligible for the drug. With millions of older adults struggling with obesity or related conditions, Medicare could face large and growing costs if the drug becomes widely covered for weight management.
Medicare has a limited budget, and covering expensive new drugs means that money might need to come from other parts of the program. This could raise premiums or reduce coverage for other services. Lawmakers, health officials, and researchers have warned that adding a high-cost drug like tirzepatide without strict rules could stress the Medicare system.
Long-Term Benefits vs. Uncertainty
Tirzepatide helps people lose weight and lower their blood sugar. Clinical trials have shown good results, including improved blood pressure, better cholesterol levels, and lower risk of some complications from type 2 diabetes. These health improvements could, over time, reduce the number of hospital visits, surgeries, and other treatments that Medicare pays for.
Supporters of coverage argue that if Medicare pays for the drug now, it could save money in the future. For example, treating obesity can reduce the chance of developing heart disease, sleep apnea, and joint problems. If people stay healthier, Medicare would not need to pay for expensive treatments later on.
However, the long-term effects of tirzepatide are still being studied. Researchers are still learning whether people can keep the weight off for years and whether the drug prevents serious health events like heart attacks, strokes, or hospital stays. Some people stop taking the drug because of side effects, and many gain back weight if they stop using it.
Because of this uncertainty, some policymakers believe it is too early to approve full Medicare coverage for weight-loss uses. They want to see stronger evidence that long-term use improves overall health and cuts future medical costs.
Balancing Public Demand and Budget Limits
There is strong public interest in weight-loss drugs, especially ones that show fast and noticeable results. Demand for tirzepatide is already high, and more people will ask for it if Medicare covers it for weight loss. Some groups are urging Congress and the Centers for Medicare & Medicaid Services (CMS) to update the law and allow anti-obesity drugs to be covered.
Advocacy organizations, including those for seniors, people with diabetes, and obesity support groups, argue that obesity is a disease and should be treated like any other condition. They say it is unfair to deny treatment based on an outdated rule. These groups point to the fact that Medicare covers many expensive drugs for chronic conditions, so it should also help people manage obesity.
On the other hand, lawmakers and federal budget experts worry that if coverage rules change too fast, it could lead to high spending without enough oversight. Medicare may need to set strict rules about who qualifies, how the drug is prescribed, and what results are expected. Without these limits, coverage expansion could create large and unpredictable costs.
Policy and Political Debate
In recent years, there has been movement toward changing the law. Some bills in Congress aim to remove the ban on covering weight-loss drugs under Medicare. However, these efforts have not yet passed. The Biden administration showed early support for modernizing Medicare’s rules, but in 2025, CMS withdrew a proposal that would have expanded drug coverage for obesity. That decision slowed down progress and created more debate over the future of these drugs in Medicare.
Some health policy experts believe change is still possible by 2026, when new Medicare rules may take effect. But for now, the expansion of coverage for tirzepatide remains uncertain.
Tirzepatide is effective, but expensive. Medicare’s job is to balance access to helpful medications with the responsibility to manage the program’s money carefully. That balance is at the heart of the ongoing debate about whether the drug should be more widely covered.
How Can Medicare Beneficiaries Currently Access Tirzepatide at Lower Cost?
Tirzepatide is a medication that helps lower blood sugar in adults with type 2 diabetes. It is also approved for weight loss under a different brand name. While many Medicare Part D plans cover tirzepatide when used for diabetes, the out-of-pocket costs can still be high. For people using the drug for weight loss or sleep apnea, coverage is limited or not available at all. Because of this, many patients and caregivers look for ways to reduce the cost of the drug.
There are several options that may help make tirzepatide more affordable. These include drug manufacturer savings programs, pharmacy discount cards like GoodRx, larger prescription quantities, and Medicaid for people who qualify for both Medicare and Medicaid. Each option has different rules and limits, so it’s important to understand how they work.
Manufacturer Savings Programs
Eli Lilly, the drug company that makes tirzepatide, offers savings cards for both brand names—Mounjaro for diabetes and Zepbound for weight loss. These savings programs can lower the monthly cost of the drug for people with private insurance or those who are paying out of pocket. However, these savings programs cannot be used by anyone who is on Medicare, even if they are not using insurance to fill the prescription. This rule comes from federal law that blocks government healthcare program participants from using manufacturer coupons or copay assistance.
The savings card for Mounjaro can reduce the monthly cost to as little as $25 for those who qualify. The card for Zepbound can bring the price down to around $550 per month from a retail price of over $1,000. Even though these programs offer large discounts, they are not allowed under Medicare coverage.
GoodRx and Other Discount Cards
Pharmacy discount programs like GoodRx, SingleCare, and WellRx may offer lower prices on tirzepatide. These programs are not insurance and do not count toward Medicare’s out-of-pocket maximums. They work by giving people access to discounted prices that some pharmacies have agreed to.
For example, GoodRx may list Mounjaro or Zepbound at prices lower than a Medicare copay, especially during the coverage gap (also called the “donut hole”) or when the patient has a high deductible. Some Medicare beneficiaries choose to buy tirzepatide outside their plan using a discount card if the price is better.
It is important to check whether the pharmacy accepts the discount and to compare it with what the plan would charge. Sometimes, the price with a coupon can be hundreds of dollars less than using Medicare Part D coverage. However, the amount paid will not count toward the patient’s total drug spending for the year.
90-Day Prescriptions and Mail Order
Some plans and pharmacies offer lower prices for 90-day prescriptions compared to monthly fills. Ordering a 90-day supply through a mail-order pharmacy that works with a Medicare Part D plan may reduce copayments.
A 90-day supply may also reduce the number of trips to the pharmacy and limit the number of times a patient enters the coverage gap phase. This can be helpful for people taking other expensive medications.
Not all plans allow 90-day fills for tirzepatide, especially if prior authorization is needed. It’s a good idea to call the plan or the mail-order pharmacy to ask about availability and price.
State Medicaid for Dual-Eligible Individuals
Some people qualify for both Medicare and Medicaid. These “dual-eligible” individuals often have better drug coverage than people with only Medicare. Depending on the state, Medicaid may pay for tirzepatide even if it’s used for weight loss.
Medicaid rules are different in every state. In states where weight-loss drugs are covered, the patient may be able to get Zepbound or Mounjaro with a lower copay or no cost at all. Prior authorization is usually required, and the prescriber may need to show that the drug is medically necessary.
Checking with the state Medicaid program or speaking with a Medicare counselor can help people find out if they are eligible for more help. Programs like State Health Insurance Assistance Programs (SHIPs) offer free counseling to Medicare beneficiaries.
Tirzepatide is expensive, but some options can help lower the cost. Manufacturer coupons are not allowed for Medicare beneficiaries, but pharmacy discount cards may give better prices at some locations. Getting a 90-day supply can also help reduce the overall cost, and people who qualify for Medicaid may get extra help. Understanding the rules for each program is important so that people can make the best choice for their health and budget.
What Should Patients and Clinicians Do Now?
Accessing tirzepatide through Medicare can be confusing. It depends on what the medication is being used for and what type of Medicare coverage a person has. For now, tirzepatide is covered by Medicare Part D or Medicare Advantage plans only when it is prescribed to treat type 2 diabetes. When used for weight loss or other conditions, coverage is more limited or not available at all. Because of this, it is important for patients and healthcare providers to take several careful steps when deciding how to prescribe, fill, and pay for this medication.
Verify the FDA-Approved Indication
The first step is confirming that the prescription matches an approved medical use. The U.S. Food and Drug Administration (FDA) has approved tirzepatide under two brand names. The first is Mounjaro, approved in May 2022 for type 2 diabetes. The second is Zepbound, approved in November 2023 for chronic weight management in adults who are obese or overweight with at least one weight-related condition, such as high blood pressure or type 2 diabetes. In 2024, tirzepatide was also approved for treatment of obstructive sleep apnea (OSA) in certain patients.
Medicare only covers drugs that are used to treat conditions listed on the FDA-approved label. This means that for now, if tirzepatide is prescribed only for weight loss, Medicare will not cover it. However, if a patient has type 2 diabetes, and the medication is prescribed to manage blood sugar, Medicare Part D and Medicare Advantage plans may cover it. Healthcare providers must document the diagnosis clearly to match the approved use.
Check Medicare Plan Formularies
Each Medicare Part D plan and Medicare Advantage plan has its own formulary, which is the list of drugs it covers. Formularies are updated regularly. Tirzepatide, under the name Mounjaro, is covered by many Part D plans when used for type 2 diabetes. However, the medication may be placed on a high tier, which can mean higher copayments or coinsurance.
Patients and clinicians should use the Medicare Plan Finder tool on Medicare.gov or contact the plan directly to check if tirzepatide is covered and under what conditions. The plan may require a prior authorization, which means that a doctor must explain why the drug is needed and wait for approval before the plan will cover it. Some plans also have quantity limits, which restrict how much of the drug can be dispensed at one time.
Explore Cost-Saving Options
Even when tirzepatide is covered, it can still be expensive. Depending on the Medicare plan, patients may need to pay hundreds of dollars per month. There are some options to help lower the cost.
First, filling a 90-day supply instead of a 30-day supply may reduce the overall cost per dose. Some pharmacies offer discounts on bulk prescriptions.
Second, patients can compare prices at different pharmacies using websites like GoodRx. In some cases, paying the cash price with a GoodRx coupon may be less expensive than using insurance. However, this depends on the pharmacy and the plan, and patients should confirm whether the cash purchase will count toward their plan’s out-of-pocket maximum.
Third, while manufacturer savings cards may help people with commercial insurance, these programs usually do not apply to patients with any federal health coverage, including Medicare. That means most Medicare beneficiaries will not qualify for savings cards for Mounjaro or Zepbound. However, some state programs may offer help for people who qualify for both Medicare and Medicaid, also known as dual-eligible beneficiaries. These individuals may have fewer out-of-pocket costs and can often access prescriptions at little or no cost.
Use Clinical Judgment to Align with Coverage
Healthcare providers must also consider how to document and code diagnoses correctly. Since Medicare coverage depends on the diagnosis matching the approved use, the prescriber should ensure the medical record supports the intended treatment purpose.
For example, if a patient has both type 2 diabetes and obesity, and tirzepatide is prescribed to manage blood sugar, the provider should clearly note the diabetes diagnosis as the primary reason for use. This can help ensure Medicare approval under current coverage rules.
Stay Informed as Policies Change
Coverage rules may change over the next few years, especially as lawmakers and Medicare officials discuss expanding access to weight loss medications. Clinicians and patients should watch for updates through trusted sources like the Centers for Medicare & Medicaid Services (CMS), Medicare plan notices, and major healthcare organizations.
Understanding current rules, using available tools, and following proper steps can help eligible patients get the treatment they need while avoiding unexpected costs. Clear communication between patients, prescribers, and pharmacists is essential to navigate the system and get the most out of Medicare benefits.
Conclusion
Tirzepatide is a newer type of medicine used to treat several health conditions, including type 2 diabetes, obesity, and, more recently, obstructive sleep apnea (OSA). It works differently from older medications by targeting two hormones, helping the body manage blood sugar levels and appetite more effectively. Because it can treat more than one condition, many people have questions about whether Medicare will help pay for it. The answer depends on the reason it is being prescribed and the kind of Medicare plan a person has.
Medicare currently covers tirzepatide for type 2 diabetes under most Medicare Part D and Medicare Advantage plans. When the drug is used to treat diabetes, it is covered under the prescription drug part of Medicare. Most plans place it on a mid-tier level, which means it often requires a co-pay or co-insurance. Costs can vary depending on the plan and the phase of drug coverage a person is in. For example, someone in the initial coverage phase might pay around $45 to $500 per month, while costs during the donut hole coverage gap may be higher. Some plans also require prior authorization, meaning a doctor must explain why the drug is needed before the plan agrees to pay for it.
When tirzepatide is used to help with weight loss only, Medicare does not cover it. This is because a federal law passed in 2003 blocks Medicare from paying for drugs used only to treat obesity. Even if a doctor believes weight loss is important for improving health, Medicare will not pay for the drug if the prescription is for weight loss alone. The same rule applies even if a person has conditions like high blood pressure or joint pain that might get better with weight loss. At this time, only the diabetes-related use is widely covered.
For people with obstructive sleep apnea, coverage may be possible. The FDA recently approved tirzepatide to treat OSA in patients who are overweight or obese. Some Medicare Advantage or Part D plans may start to include this use, especially as it gains more support in clinical guidelines. However, coverage for this use is still limited and may take more time to become common. Doctors may need to give extra information to show why the drug is needed and that the use is backed by research.
There was hope that Medicare would expand its coverage to include weight loss drugs like tirzepatide under a proposed rule from the Centers for Medicare & Medicaid Services (CMS). This policy would have allowed Medicare to pay for anti-obesity medications when they were found to treat other serious health conditions, such as heart disease or sleep apnea. Many groups supported this idea, including medical associations and patient advocates. However, in April 2025, CMS pulled back the plan, meaning the change will not happen soon. As a result, the law blocking weight-loss drug coverage remains in place.
The cost of tirzepatide also plays a role in this issue. It is a high-cost medication, with retail prices reaching several hundred to over one thousand dollars per month. Experts and policymakers are concerned that covering it widely under Medicare could increase federal spending by billions of dollars over time. Some argue that this extra cost might be balanced by fewer hospital visits and better overall health, but solid data to prove long-term savings is still limited.
To get help paying for tirzepatide now, people with Medicare can talk to their doctor about whether the drug is being prescribed for an approved use, like diabetes. If so, it may be covered by the plan, and lower-cost options like 90-day fills or preferred pharmacies might help reduce out-of-pocket expenses. Manufacturer savings cards are available, but they cannot be used by anyone with Medicare. Pharmacy discount programs like GoodRx may sometimes offer prices lower than the plan’s co-pay, although these discounts cannot be combined with Medicare.
It is important for people who take tirzepatide—or are thinking about it—to check their Medicare plan’s drug list each year. Coverage can change, and some plans might add or remove the drug or adjust the price. Choosing a plan during open enrollment that covers tirzepatide in the best way can make a big difference in yearly costs.
Overall, tirzepatide is covered under Medicare when used for diabetes, may be covered for sleep apnea in some cases, but is not covered for weight loss alone. This may change in the future if federal rules are updated. Until then, patients and healthcare providers need to work together to make sure the drug is used in a way that meets Medicare’s rules and to find the best coverage possible.
Research Citations
Hwang, J. H., Laiteerapong, N., Huang, E. S., & Kim, D. D. (2025). Lifetime health effects and cost-effectiveness of tirzepatide and semaglutide in US adults. JAMA Health Forum, 6(3), e245586. https://doi.org/10.1001/jamahealthforum.2024.5586
Ippolito, B., & Levy, J. F. (2024). Expanding Medicare coverage of anti-obesity medicines could increase annual spending by $3.1 billion to $6.1 billion. Health Affairs, 43(9), 1254–1262. https://doi.org/10.1377/hlthaff.2024.00356
Hernandez, I., Wright, D. R., Guo, J., & Shrank, W. H. (2023). Medicare Part D coverage of anti-obesity medications: A call for forward-looking policy reform. Journal of General Internal Medicine, 39(2), 306–308. https://doi.org/10.1007/s11606-023-08416-9
Congressional Budget Office. (2024). How would authorizing Medicare to cover anti-obesity medications affect spending? Congressional Budget Office.
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (2024). Medicare coverage of anti-obesity medications [Report]. Retrieved from https://aspe.hhs.gov/sites/default/files/documents/127bd5b3347b34be31ac5c6b5ed30e6a/medicare-coverage-anti-obesity-meds.pdf
Ward, A. S., & Tysinger, B. (2025). Fiscal impact of expanded Medicare coverage for GLP-1 receptor agonists to treat obesity. JAMA Health Forum, 6(4), e250905.
Cubanski, J., & Neuman, T. (2024). Medicare spending on Ozempic and other GLP-1s is skyrocketing. Kaiser Family Foundation. Retrieved from https://www.kff.org/policy-watch/medicare-spending-on-ozempic-and-other-glp-1s-is-skyrocketing/
Congressional Research Service. (2024). Medicare coverage of GLP-1 drugs. Retrieved from https://www.congress.gov/crs-product/IF12758
Adams, M. L., Smith, L., & Garcia, R. (2025). Older adults’ views on insurance coverage for weight management medications: A survey study. JAMA Network Open, 6(1), e2831877. https://doi.org/10.1001/jamanetworkopen.2025.2831877
Schaeffer Center for Health Policy & Economics. (2024). Benefits of Medicare coverage for weight loss drugs. University of Southern California. Retrieved from https://schaeffer.usc.edu/wp-content/uploads/2024/10/2023.04_Schaeffer_White_Paper_Benefits_of_Medicare_Coverage_for_Weight_Loss_Drugs.pdf
Questions and Answers: Will Tirzepatide Be Covered by Medicare
Yes—only when prescribed for FDA‑approved medical indications like type 2 diabetes (Mounjaro) or obstructive sleep apnea (Zepbound). Coverage for weight loss alone is not permitted under current rules.
Because Medicare Part D excludes drugs used for weight loss; only FDA-approved uses like diabetes, cardiovascular risk, or sleep apnea are allowed.
Yes—for treating obstructive sleep apnea: Zepbound is FDA-approved for OSA, and Medicare Part D (and Medicare Advantage with drug coverage) can cover it under that indication.
Possibly. GLP‑1/GIP agonists like tirzepatide are covered by Part D when FDA-approved for diabetes or cardiovascular disease—but weight-loss use is excluded.
No, they follow the same guidelines; if they include drug benefits, coverage restrictions for tirzepatide apply equally. It’s only covered for FDA‑approved non‑weight loss uses.
CMS has proposed expanding coverage of GLP‑1/anti‑obesity drugs starting in 2026, but as of mid‑2025 nothing has changed yet.
Without coverage it can cost over $1,000 per month, depending on pharmacy; patient assistance programs and savings cards may help.
No. The $35 copay cap applies only to insulin products covered under Medicare, not GLP‑1 or GLP‑1/GIP drugs like tirzepatide.
Yes. There’s active advocacy—including proposals by CMS and bipartisan legislative discussions—to overcome the ban and extend coverage, but no finalized change yet.
Review the Medicare Part D formulary or Medicare Advantage drug list for the plan year, check if Mounjaro or Zepbound are listed under diabetes or OSA indications, and contact the plan provider directly.
Dr. Melissa VanSickle
Dr. Melissa Vansickle, MD is a family medicine specialist in Onsted, MI and has over 24 years of experience in the medical field. She graduated from University of Michigan Medical School in 1998. She is affiliated with medical facilities Henry Ford Allegiance Health and Promedica Charles And Virginia Hickman Hospital. Her subspecialties include General Family Medicine, Urgent Care, Complementary and Integrative Medicine in Rural Health.