Is Zepbound Covered by Medicare?

Zepbound is a popular weight loss drug that’s helped many people shed pounds. But if you’re on Medicare, you might wonder about coverage. This article explains whether Medicare covers Zepbound in simple, easy-to-read language.

We’ll cover what Zepbound is, how Medicare works with weight loss drugs, and what’s changing in 2025. It’s all about giving you the facts so you can plan ahead. Let’s get started.

What Is Zepbound?

Zepbound is a weekly injection made by Eli Lilly. Its active ingredient, tirzepatide, helps control hunger by mimicking two hormones: GLP-1 and GIP. This slows digestion and makes you feel full longer.

The FDA approved Zepbound in November 2023 for weight loss in adults with obesity. It’s also approved for people overweight with conditions like high blood pressure. In December 2024, it got approval for obstructive sleep apnea (OSA) too.

It’s not a cheap drug—without insurance, it costs over $1,000 a month. That’s why many ask, “Is Zepbound covered by Medicare?” Let’s look at how Medicare handles it.

How Medicare Covers Prescription Drugs

Medicare has different parts, and each covers specific things. Part D is the part that helps with prescription drugs like Zepbound. It’s offered through private insurance plans you can join.

Part B covers doctor visits and some medications, but not self-injected drugs like Zepbound. Medicare Advantage (Part C) plans often include Part D benefits. Coverage depends on your plan’s rules.

Historically, Medicare hasn’t covered weight loss drugs. A law from years ago says they’re excluded unless used for another health reason. That’s been the sticking point for Zepbound.

Zepbound and Weight Loss: The Current Rule

Right now, Medicare doesn’t cover Zepbound if it’s prescribed just for weight loss. The law sees obesity drugs as non-essential for this purpose. So, if your doctor writes it for shedding pounds, you’d pay full price.

This rule has frustrated many beneficiaries. Obesity affects millions of older adults, raising risks for heart disease and diabetes. Yet, Medicare won’t budge on weight loss alone.

Things shift when Zepbound is used for something else. The FDA’s extra approvals open new doors. Let’s see how that changes things.

Coverage for Other Health Conditions

Medicare Part D can cover Zepbound if it’s prescribed for a condition beyond weight loss. In December 2024, the FDA approved it for obstructive sleep apnea in obese adults. This was a big deal.

The Centers for Medicare & Medicaid Services (CMS) confirmed in January 2025 that Part D plans can cover Zepbound for OSA. It’s not about weight loss here—it’s about treating a sleep disorder.

Other uses might get coverage too. For example, tirzepatide (Zepbound’s ingredient) is in Mounjaro, covered for diabetes. If Zepbound gets similar approvals, Medicare might step in.

What’s Happening in 2025 and Beyond

Big changes could be coming. In November 2024, the Biden administration proposed a rule to cover weight loss drugs like Zepbound for obesity itself. This would flip the old law on its head.

If approved, this change starts in 2026. It would help 3.4 million Medicare users and 4 million on Medicaid. But it’s not final—the incoming Trump administration must sign off.

The proposal isn’t cheap. It could cost Medicare $25 billion over 10 years. Some worry about higher premiums, but supporters say it’s worth it for health benefits.

How to Check If Your Plan Covers Zepbound

Not sure if your Medicare plan covers Zepbound? Every Part D plan has a formulary—a list of covered drugs. You can find yours online or by calling your plan.

For OSA, some plans already list Zepbound. Others might add it soon since formularies can update anytime. Check with your insurer to confirm.

If it’s not covered, you might need prior authorization. This means your doctor proves it’s medically necessary. It’s a hassle, but it can work.

Costs Without Coverage

Without Medicare help, Zepbound’s price tag stings. It’s around $1,060 to $1,086 per month, depending on the dose. That’s a lot for most budgets.

Eli Lilly offers a savings card for people with commercial insurance. It drops the cost to as low as $25 a month. But Medicare patients can’t use it—government rules block it.

Some turn to out-of-pocket options. LillyDirect sells vials at $399 for 2.5 mg or $549 for 5 mg. It’s still pricey but cheaper than the full pen price.

Medicare Advantage and Medigap Options

Medicare Advantage plans (Part C) might offer more flexibility. Some include drug coverage beyond standard Part D. A few even cover weight loss programs.

Check your Advantage plan’s formulary for Zepbound. It might cover it for OSA now or obesity later if the rule changes. Costs vary, so compare plans during open enrollment.

Medigap helps with copays and deductibles, not drugs. You’d still need Part D for Zepbound. It’s a combo to consider if costs pile up.

Table: Zepbound Coverage by Medicare Part

Here’s a quick breakdown of where Zepbound fits with Medicare:

This table shows the current setup. Part D is your best bet for coverage right now.

What If Medicare Doesn’t Cover It?

If Zepbound isn’t covered, you’ve got options. Talk to your doctor about alternatives like Mounjaro, which Medicare covers for diabetes. It’s the same drug, different label.

You could also appeal a denial. Medicare plans must let you challenge their decisions. Your doctor can help with paperwork to make your case.

Another route is paying out of pocket. It’s not ideal, but Lilly’s vial program cuts costs. Weigh the price against the benefits with your doctor.

Real Stories from Medicare Users

People’s experiences vary. One 67-year-old with OSA got Zepbound covered under Part D in early 2025. Their copay was $50 a month—way better than $1,000.

Another user, wanting it for weight loss, struck out. Their plan wouldn’t budge, and they couldn’t afford it solo. They’re hoping the 2026 rule passes.

A third switched to an Advantage plan with extra benefits. It didn’t cover Zepbound yet, but they got fitness help instead. It’s all about finding what fits.

Lifestyle and Zepbound Together

Even with coverage, Zepbound works best with healthy habits. Eating fewer calories—like veggies and lean protein—boosts its effects. Exercise helps too.

Doctors stress this combo for OSA or weight goals. Medicare might not cover gym memberships, but some Advantage plans do. It’s a team effort.

If you’re waiting on coverage, start small. Walking 20 minutes a day costs nothing. It’s a step forward while you sort out the drug part.

The Future of Zepbound and Medicare

The 2026 proposal could change everything. If it goes through, is Zepbound covered by Medicare won’t be a tricky question anymore. Obesity would count as a covered condition.

Experts debate the cost. Some say it’s too much for Medicare to handle. Others argue it saves money long-term by cutting obesity-related illnesses.

For now, coverage hinges on OSA or future approvals. Stay tuned—2025 decisions will shape what’s next. Check with Medicare yearly for updates.

Summary

Zepbound is a weight loss drug with growing uses, like treating sleep apnea. Right now, Medicare Part D covers it for OSA but not for weight loss alone. That’s due to an old law limiting obesity drug coverage.

A proposed rule could change that in 2026, covering Zepbound for obesity. It’s not set yet—costs and politics will decide. For now, check your Part D plan for OSA coverage.

Without coverage, it’s expensive, but options like LillyDirect help. Pair it with diet and exercise for the best shot. Medicare’s rules are evolving, so keep an eye out.

FAQ Section

Is Zepbound covered by Medicare for weight loss?
No, not yet—it’s excluded unless used for another condition. A 2026 rule might change that.

Can Medicare cover Zepbound for sleep apnea?
Yes, Part D plans can cover it for OSA since the FDA approved it in 2024.

How do I know if my plan covers Zepbound?
Look at your Part D formulary or call your plan. It might need prior authorization.

What’s the cost if Medicare doesn’t cover it?
It’s about $1,060 a month. Lilly’s vials are $399-$549 if you pay yourself.

Will Medicare cover Zepbound in the future?
Maybe—if the 2026 proposal passes, obesity could qualify. It’s up to the next administration.