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tdwjack
Contributor ⭐
December 19, 2025

Weight Loss Medication

  • December 19, 2025
  • 3 replies
  • 1228 views

my primary physician has submitted request for Zepbound and I am being continuously denied by Medicare. I have several healthcare problems and Medicare keeps denying me. I am wondering if there are others like me who are on Medicare, but has a weight problem and continuously or denied help. Look forward to hearing from others who have experienced this.

    3 replies

    GailL1
    GailL1
    Community Champion ⭐⭐⭐
    December 19, 2025

    @tdwjack 

    Medication solely for the purpose of weight loss is prohibited by the overall program of Medicare - Stand alone Part D plans and Medicare Advantage plans where the Prescription drug coverage is embedded within the plan.

     

    However, if the [specific] medication has been approved by the FDA as also helping with other health problems, then you just have to find a plan that covers it just like any other medication.

     

    Some of them are approved for FDA-approved conditions like Type 2 diabetes, cardiovascular disease, or sleep apnea,  

     

    AARP has been running a number of articles on these GLP-1 drugs.

    AARP.org 11/18/2025 - Are Weight Loss Drugs About to Get Less Expensive? 

     

    AARP.org 11/21/2025 - When Will Medicare Cover Ozempic, Other Weight-Loss Drugs? 

     

    AARP.org - 11/21/2025- When Will Medicare Cover Ozempic, Other Weight-Loss Drugs? 

     

    AARP.org- 11/25/2025 - Second Round of Medicare-Negotiated Price Cuts Expected to Save Billions in Drug Costs in 2027 

     

    The current administration is trying to remove the Medicare/ Medicaid rule of no coverage specifically for just weight loss but some of the problem is coming down to money since these are very expensive meds.  However, some of them are now being included in the drugs that are being negotiated for inclusion in 2027 plans.

    TrumpRx is supposed to be up and running in 2026.  

     

    WhiteHouse.gov - 11/05/2025 - Fact Sheet - President Donald J. Trump Announces Major Developments in Bringing Most-Favored-Nation Pricing to American Patients 

     

    So, it seems you may have to wait a bit longer but if some of your other health conditions are listed as an FDA approved usage, then your doc has to specific that and it is documented in your medical file - then if your formulary does not covered the specific one you need for this condition, you may have to ask for an exception until you can change plans next year during the AEP.

     

    Zepbound is FDA approved for the sleep apnea.  

    FDA.gov 12/20/2024 - FDA Approves First Medication for Obstructive Sleep Apnea 

     

    Hope this helps you some.  

     

    IT‘S ALWAYS SOMETHING . . . . .. . . . Roseanne Roseannadanna
    T
    tdwjackAuthor
    Contributor ⭐
    December 20, 2025

    Thank you so much for your response. My primary physician listed all of my medical conditions which included sleep apnea, and I also have cardiac stenosis. We are going to a pill their denial, but thank you for the information. 

    GailL1
    GailL1
    Community Champion ⭐⭐⭐
    December 20, 2025

    @tdwjack 

    Hopefully, your doc knows this but he has to be very specific on which GLP-1 medication for which malady he is prescribing it and also your BMI may have to be within a certain level.  The way the FDA approval was given for each type of GLP-1 is critical.  It isn’t either / or - it is very specific - 

     

    Zepbound was definitely sleep-apnea and Wecovy and Ozempi was some cardiovascular conditions. So that may be a problem since you have some of both.

     

    There are lots of others too.  Then it has to be ON formulary or then you have to get the exception.  

     

    Someday, I am sure that these meds are gonna be on just about all formularies but right now with their cost - it is all about their cost especially since the insurance companies and the drug manufacturers are picking up so much of the cost too of these meds. 

     

    Right now, It is all about your condition(s) , your specific weight, BMI ratio and which med is the best for all of these things put together.  

     

    Good Luck - 

     

     

    IT‘S ALWAYS SOMETHING . . . . .. . . . Roseanne Roseannadanna
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