Medicare and Medicaid will not expand coverage to anti-obesity medications

The US Centers for Medicare & Medicaid Services (CMS) confirmed that it will not proceed with a Biden administration proposal to expand Medicare coverage for anti-obesity drugs such as Novo Nordisk’s Wegovy (semaglutide) and Eli Lilly’s Zepbound (tirzepatide).

The US government has decided not to implement a proposal that would have allowed Medicare and Medicaid to cover anti-obesity medications for weight loss. Many Medicare and Medicaid beneficiaries on limited income cannot afford these medications otherwise.

Medicare Part D has always denied coverage of drugs that are used for weight loss. Companies have side-stepped this rule by expanding their obesity drugs into indications that Medicare covers. Novo, for instance, broadened Wegovy’s label with a cardiovascular approval in March 2024, winning Medicare coverage a few weeks later. Lilly made a similar move with Zepbound, which was approved for obstructive sleep apnea in December 2024 before securing Medicare coverage in January.

However, the Biden administration in November 2024 proposed to include these agents for their obesity indications in the Part D program, with the goal of improving Americans’ access to these “transformative” therapies, according to the CMS fact sheet at the time.

“CMS’ revised interpretation would recognise obesity to be a chronic disease based on changes in medical consensus,” the agency wrote in November, however emphasising that weight-loss drugs would only be covered for patients with obesity.

According to the Endocrine Society, this decision leaves in place a major barrier that prevents millions of Americans from receiving appropriate and evidence-based obesity treatment and care. More than two in five adults nationwide are living with obesity, according to the Society’s Obesity Playbook. Obesity-related medical care costs total $173 billion a year in the US.

A new generation of GLP-1s anti-obesity medications have given clinicians new tools to help people with this chronic condition. However, clinicians are often waiting too long to prescribe anti-obesity medications due to insurance coverage issues. When patients are forced to delay treatment, it puts them at risk of developing other chronic diseases and medical conditions. People living with obesity are at increased risk of developing over 230 complications, including cancer, type 2 diabetes, heart disease, liver diseases and kidney diseases.

The Society said that current policy makes anti-obesity medications less accessible and more costly for patients. The Society will continue to advocate for Congress to pass legislation to expand Medicare and Medicaid coverage of anti-obesity medications and for the administration to take immediate action on this issue.

These drugs, which cost around $1,100 per month, would have cost Medicare and Medicaid about $166 billion per year if half of beneficiaries who are obese took these medications.

In October 2024, the Congressional Budget Office released a report warning that authorsing these anti-obesity treatments for Medicare coverage could increase federal spending by around $35 billion from 2026 to 2034. Meanwhile, the total savings from improved health “would be small,” according to the report, totalling under $50 million in 2026 and around $1 billion in 2034.