Medicare + Medicaid to Cover Zepbound? Here’s Why It’s Not as Simple as It Sounds!

Medicare might finally be catching up to what we’ve known for years: obesity isn’t just about weight, and it’s definitely not a personal failing—it’s a chronic disease. In a move that could change the lives of millions, Medicare is proposing to expand coverage for anti-obesity medications (AOMs) under Part D and Medicaid. This isn’t just a small tweak. It’s a major shift, and the ripple effects could reshape how we think about obesity, access to treatment, and even health equity in this country.

But there’s a lot more to this story than just coverage changes. The timing couldn’t be more interesting, with a new administration set to take over in 2025, RFK Jr. could has been tapped to lead the NIH and has been making waves about GLP-1 drug prices, while Dr. Marty Makary, Chief Medical Officer at an obesity treating telehealth company could land at the top of the FDA. Let’s break it all down.

Medicare’s History of AOM Exclusion

For nearly two decades, Medicare Part D has excluded medications labeled for “weight loss.” That’s because the Social Security Act let Medicaid—and by extension, Medicare—exclude drugs used for anorexia, weight loss, or weight gain. This blanket exclusion stuck, even as science evolved to recognize obesity as a chronic disease requiring medical treatment.

Here’s the frustrating part: even medications prescribed to treat obesity, like GLP-1 receptor agonists (Saxenda, Wegovy, Zepbound), didn’t make the cut. The result? Millions of people were left paying out-of-pocket for these life-changing treatments. Efforts like the Treat and Reduce Obesity Act tried to fix this, but they ultimately fell short. Patients were left in the lurch, once again.

The New Proposal: What’s Changing

Now, Medicare is proposing a new way forward. Here’s what it looks like:

• Coverage for AOMs (anti-obesity medications): Medicare Part D would cover medications prescribed for obesity treatment, specifically to reduce or maintain weight loss for people with an obesity diagnosis and BMI greater than 30.

• Medicaid Alignment: Medicaid programs would also be required to cover certain anti-obesity medications, an attempt to address longstanding disparities in access.

• Limits Still Apply: If a medication is prescribed purely for weight loss without an obesity diagnosis, it’ll still be excluded.

This is huge. It recognizes obesity as a disease and aligns federal policy with where medicine is today. But let’s be clear: this isn’t a cure-all, and it doesn’t cover everything. Still, it’s progress.

What’s Next: Timing Is Everything

Here’s where it gets really interesting. The proposed changes are set to roll out in 2026, assuming the rule is finalized. That timing lines up with some big political shifts:

• The Trump Administration: With a new administration taking over in 2025, the political landscape could shape how this rule is implemented. Trump’s policies around healthcare and drug pricing will undoubtedly play a role.

• RFK Jr.’s Influence: RFK Jr. has been vocal about the high cost of GLP-1 medications. His push to bring attention to drug pricing could intersect with Medicare’s expanded coverage and further amplify the conversation.

• Potential FDA Shake-Up: There’s speculation that Dr. Marty Makary, known for his ties to Sesame Health and his criticism of Big Pharma, could take a key role at the FDA. Makary has been a proponent of affordable healthcare and compounded medications, which might create an interesting dynamic for GLP-1 drugs and their pricing.

This timing isn’t just coincidence—it’s a convergence of policy, politics, and patient advocacy that could reshape the landscape of obesity treatment.

What This Means for Patients

For people on Medicare and Medicaid, this proposal is a game changer. Anti-obesity medications aren’t cheap—Wegovy, for example, runs over $1,100 a month without insurance. Expanding coverage could make these treatments accessible to millions who’ve been priced out.

And let’s not forget the meta picture here. Treating obesity isn’t just about weight—it’s about preventing or managing the host of conditions that often come with it, like diabetes, heart disease, and joint issues. Medicare stepping up to cover these treatments could reduce long-term healthcare costs while improving quality of life for countless individuals.

Still Some Medicaide Shortfalls

While the CMS proposal requires Medicaid programs to cover anti-obesity medications (AOMs) for treating obesity, it doesn’t eliminate disparities entirely. States retain flexibility in how they implement this coverage, which could result in significant variations. For instance, states can decide which medications to include in their formularies, potentially excluding higher-cost options like GLP-1 receptor agonists. They may also impose administrative hurdles, such as prior authorization or step therapy requirements, delaying or complicating access. Additionally, states might define “medical necessity” narrowly, limiting coverage to patients with severe obesity or specific comorbidities. These factors could create a patchwork system where patients in some states have easier access to AOMs, while others face significant challenges.

The Big Picture

This isn’t just about Medicare and Medicaid. It’s about a shift in how we, as a society, view obesity and the people living with it. For decades, stigma has kept obesity care in the shadows, treated as a personal failing rather than a disease. This proposal starts to change that narrative.

But it also comes with questions. How will RFK Jr.’s crusade against GLP-1costs play out alongside this? How might Dr. Makary's potential appointment to the FDA impact this decision? And will this move by Medicare spark broader changes in how private insurers cover obesity treatments?

The answers aren’t clear yet, but one thing is: this is a moment for patients, advocates, and policymakers to come together and keep pushing for better access, better care, and a better future.

Stay tuned to OnThePen.com for more updates on this developing story and what it means for patients on GLP-1 medications. And if this resonates with you, share this article in your networks—whether it’s in Facebook groups, on Reddit, or with friends. Together, we can make our voices heard and keep advocating for a world where obesity care is recognized as essential, not optional.