THE SHORT ANSWER
Does Medicare Cover Zepbound?
Yes—Medicare Can Now Cover Zepbound (Two Pathways)
As of July 1, 2026, Medicare can cover Zepbound for weight loss through the Medicare GLP-1 Bridge, a temporary CMS program that runs outside your Part D benefit: a flat $50 per monthly fill for the Zepbound KwikPen only, if you have eligible Part D coverage, meet CMS's eligibility criteria and your prescriber gets prior authorization.[29] Separately, Zepbound may be covered under Part D when it's prescribed for obstructive sleep apnea (OSA), and tirzepatide (as Mounjaro) for type 2 diabetes, subject to the plan's formulary, prior authorization and exceptions process.[1]
Which pathway applies to you depends on why Zepbound is prescribed and which Medicare plan you have:
- For weight loss: The Medicare GLP-1 Bridge now covers the Zepbound KwikPen at $50 per monthly fill for people with eligible Part D coverage who meet CMS's criteria (BMI-based tiers + prior authorization). Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026.
- For obstructive sleep apnea (OSA): May be covered under Part D, subject to the plan's formulary, prior authorization and exceptions process (people with moderate-to-severe OSA can't use the Bridge)
- For type 2 diabetes: Tirzepatide (as Mounjaro) may be covered under Part D, subject to the plan's formulary, prior authorization and exceptions process
- Medicare Advantage: Coverage for the OSA indication varies by plan
Bottom line: Medicare beneficiaries who meet the Bridge's criteria now have a weight-loss pathway for Zepbound (the $50 Bridge, KwikPen only), and Part D may cover Zepbound for OSA or tirzepatide (as Mounjaro) for type 2 diabetes, depending on the plan. The right path depends on your indication and your plan.
For a complete overview of getting Zepbound covered regardless of insurance type, see our full coverage guide.
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THE WEIGHT-LOSS PATHWAY (LIVE SINCE JULY 1, 2026)
The $50 Medicare GLP-1 Bridge
The Medicare GLP-1 Bridge is a CMS demonstration that launched July 1, 2026 and runs through December 31, 2027. It runs outside the Part D benefit and lets people with eligible Part D coverage who meet CMS's eligibility criteria, and whose prescriber gets prior authorization, get a weight-loss GLP-1 (including the Zepbound KwikPen) for a flat copay.[29]
What the Bridge Covers for Zepbound
- $50 flat monthly copay—the same regardless of dose or your Part D benefit phase[29]
- Zepbound KwikPen ONLY. Zepbound single-dose vials and single-dose pens are not covered under the Bridge—you'll need a prescription written specifically for the KwikPen[32]
- Weight-loss indication. The Bridge covers Zepbound prescribed for weight reduction and maintenance (with ongoing lifestyle modification)
- Eligibility is BMI-based, with exclusions (see below). Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization.
What the $50 Doesn't Count Toward
The Bridge copay is collected at the pharmacy, but it does not apply to your Part D deductible or your annual out-of-pocket cap, and Extra Help / LIS doesn't reduce it—even beneficiaries who normally pay only a few dollars per prescription pay the full $50.[29]
Full Bridge Guide: Eligibility, Cost & How to Apply
For the complete BMI tiers and qualifying conditions, plan-type eligibility, the cost catches, and the step-by-step prior authorization process, see our dedicated Medicare GLP-1 Bridge guide.
Quick things to check for Zepbound: that your prescription is for the KwikPen (not vials or single-dose pens), that you meet one of the Bridge's BMI tiers, that none of the exclusions apply (Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026), and that your plan type is eligible. The Bridge guide walks through each.
Bridge vs. the BALANCE Model
The Bridge is a temporary program (through Dec 31, 2027). The separate BALANCE Model, which would build weight-loss GLP-1 coverage into Part D, is delayed, with no new start date: in April 2026, CMS said BALANCE is not launching in Medicare in 2027 and extended the Bridge instead.[28] Coverage after the Bridge ends is currently undetermined.
WHY THE BRIDGE EXISTS
Part D & the Weight-Loss Exclusion
The reason Zepbound's weight-loss coverage runs through the $50 Bridge—rather than your regular Part D plan—is a long-standing federal law. Unlike commercial insurance that can choose whether to cover weight loss medications, basic Medicare Part D coverage excludes drugs used for weight loss by statute (some enhanced plans could offer them as supplemental benefits). The Bridge is a separate, temporary CMS demonstration that runs outside the Part D benefit; outside the Bridge, the exclusion still applies.
The Statutory Exclusion
42 U.S.C. § 1395w-102(e)(2)(A) cross-references the Medicaid exclusion at 42 U.S.C. § 1396r-8(d)(2), which lists "agents when used for anorexia, weight loss, or weight gain." Drugs on that list are excluded from basic Part D coverage.[2]
This law was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and remains in effect today.
What This Means for You
| Indication | Part D Coverage | Reason |
|---|---|---|
| Chronic Weight Management | Not by your Part D plan; Bridge: $50 per monthly fill (with conditions) | Excluded from basic Part D coverage by 42 U.S.C. § 1395w-102; the separate Medicare GLP-1 Bridge (outside Part D) can cover the Zepbound KwikPen, with conditions |
| Obstructive Sleep Apnea (OSA) | May Be Covered | FDA-approved indication, not excluded by statute; subject to the plan's formulary, prior authorization and exceptions process |
| Type 2 Diabetes (Mounjaro) | Check Plan | Different drug; same active ingredient |
How the Weight-Loss Pathway Opened Up
🗓️ From Announcement to Live Program
On November 6, 2025, the Trump administration announced agreements with Eli Lilly and Novo Nordisk to expand Medicare coverage of GLP-1 medications for obesity.[3][21][22]
That coverage is now live. The Medicare GLP-1 Bridge launched July 1, 2026, giving people with eligible Part D coverage who meet CMS's criteria (and get prior authorization) the Zepbound KwikPen for $50 per monthly fill.[29]
See the $50 GLP-1 Bridge section above for what's covered today, and the BALANCE Model note below for the separate BALANCE model, which is delayed in Part D with no new start date.
Who Is Eligible
How Eligibility Actually Works Under the Bridge
The live Bridge uses three BMI tiers: Age 18+ and BMI ≥35; or BMI ≥30 with HFpEF, uncontrolled high blood pressure or CKD stage 3a+; or BMI ≥27 with prediabetes, a prior heart attack or stroke, or symptomatic PAD. Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026. See the full Bridge guide for the exact tiers and conditions.[29]
What You'll Pay
| Scenario | Monthly Cost |
|---|---|
| What you pay (Bridge beneficiary copay) | $50 per monthly fill[29] |
Behind the scenes, participating manufacturers provide Bridge drugs at a net program price of $245 per monthly supply. Eligible beneficiaries pay only the $50 per monthly fill copay, not that amount. Note the $50 does not count toward your deductible or out-of-pocket cap, and Extra Help doesn't reduce it.
How We Got Here: The Timeline
| Date | What Happened |
|---|---|
| November 6, 2025 | White House announces Medicare GLP-1 coverage agreements with Lilly and Novo Nordisk[3] |
| December 23, 2025 | CMS announces the BALANCE Model as the planned permanent framework[28] |
| February 5, 2026 | TrumpRx.gov launched (TrumpRx lists the manufacturers’ own self-pay prices (not a separate, cheaper price))[21] |
| April 21, 2026 | CMS declines to implement BALANCE in Part D for 2027; extends the GLP-1 Bridge instead[28] |
| July 1, 2026 ✅ LIVE | Medicare GLP-1 Bridge launches—$50/month, Zepbound KwikPen only[29] |
| December 31, 2027 | Scheduled end of the Bridge; coverage afterward is undetermined[29] |
What About the Permanent BALANCE Model?
BALANCE in Part D Is Delayed
The BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) was the planned permanent framework to waive the Part D weight-loss exclusion.[30] On April 21, 2026, CMS declined to implement it in Part D for 2027 (status: Delayed, with no new start date) and extended the temporary GLP-1 Bridge through Dec 31, 2027 instead.[28] The Bridge—not BALANCE—is the live weight-loss pathway today.
TrumpRx: Direct-Purchase Option (February 2026)
Not Eligible for the Bridge?
TrumpRx.gov launched on February 5, 2026. TrumpRx lists the manufacturers’ own self-pay prices (not a separate, cheaper price): for Zepbound it lists Lilly's self-pay vial price, and orders go through LillyDirect. It's available to anyone paying cash, including Medicare beneficiaries:[21]
- Zepbound price: LillyDirect self-pay, $299–$449/month by dose
- Pills: Foundayo self-pay is $149–$299/month by dose
- Who can use it: Anyone paying cash (no insurance claim)
Your Pathways Today
If you're a Medicare beneficiary who wants Zepbound, here's where coverage stands now:
- Weight loss: The $50 GLP-1 Bridge (Zepbound KwikPen only). Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization.
- OSA pathway: If you have moderate-to-severe sleep apnea, Zepbound may be covered under Part D, subject to the plan's formulary, prior authorization and exceptions process (see below)
- TrumpRx: Lists LillyDirect's self-pay price ($299–$449/month); orders go through LillyDirect
- Self-pay: See our cost guide for other options
HOW ZEPBOUND MAY BE COVERED
The OSA Exception
On December 20, 2024, the FDA approved Zepbound for the treatment of moderate-to-severe obstructive sleep apnea (OSA) in adults with obesity.[4] This second indication creates a potential coverage pathway for Medicare beneficiaries.
Complete OSA Guide Available
For detailed information on the OSA indication—including clinical trial results, diagnosis steps, and how to navigate prior authorization—see our Zepbound for Sleep Apnea Guide.
Typical Plan Coverage Criteria for OSA
FDA approval covers adults with obesity and moderate-to-severe OSA. Medicare plans that cover Zepbound for OSA set their own criteria, which vary by plan (ask for yours in writing). They may require:
Clinical Criteria
- Diagnosis of moderate-to-severe OSA confirmed by sleep study
- Apnea-Hypopnea Index (AHI) ≥ 15 events/hour
- BMI ≥ 30 kg/m² (obese)[27]
- Inadequate response or intolerance to PAP therapy (CPAP/BiPAP)
- Concurrent reduced-calorie diet and increased physical activity
Required Documentation
- Sleep study results (polysomnography or home sleep apnea test)
- AHI score documented by sleep specialist
- Current BMI (height and weight within last 30 days)
- CPAP/BiPAP trial documentation showing inadequate response or intolerance
- Letter of Medical Necessity from prescribing physician
ICD-10 Codes for OSA vs. Obesity Billing
| Indication | ICD-10 Code | Medicare Coverage |
|---|---|---|
| Obstructive Sleep Apnea | G47.33 | May be covered (OSA indication) |
| Obesity, Class I (BMI 30-34.9) | E66.811 | Not by your Part D plan (weight-loss exclusion); the Bridge may cover the KwikPen |
| Obesity, Class II (BMI 35-39.9) | E66.812 | Not by your Part D plan (weight-loss exclusion); the Bridge may cover the KwikPen |
| Obesity, Class III (BMI ≥40) | E66.813 | Not by your Part D plan (weight-loss exclusion); the Bridge may cover the KwikPen |
Billing for OSA Indication
When prescribing Zepbound for the OSA indication, the primary diagnosis should be G47.33 (Obstructive Sleep Apnea); check your plan's criteria. BMI codes (Z68.3x-Z68.4x) can be added as secondary diagnoses to document eligibility but should not be the primary reason for prescribing.
Note: The E66.811/812/813 obesity class codes are new as of October 1, 2024. Some systems may still use the older E66.01/E66.09 codes.[15]
Do You Have OSA?
Many people with obesity have undiagnosed sleep apnea. Common symptoms include:
- Loud snoring, especially with witnessed breathing pauses
- Excessive daytime sleepiness despite adequate sleep time
- Waking with dry mouth, morning headaches, or gasping for air
- Difficulty concentrating or mood changes
If you have these symptoms, ask your doctor about a sleep study. A diagnosis of OSA could open a Part D coverage pathway for Zepbound, but it also means you can't use the $50 Bridge: people diagnosed with moderate-to-severe sleep apnea would need Part D coverage instead, which depends on the plan's formulary, prior authorization and exceptions process. Mild sleep apnea is not one of CMS's stated exclusions, but you must meet every other Bridge requirement.
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COVERAGE VARIES BY PLAN
Medicare Advantage Plans
Medicare Advantage (Part C) plans with prescription drug coverage (MA-PD) follow the same basic Part D exclusion for weight-loss drugs, but MA-PD members can use the GLP-1 Bridge if they meet CMS's criteria; coverage for the OSA indication varies by plan.
| Plan Type | Weight Loss Coverage | OSA Coverage | Notes |
|---|---|---|---|
| Original Medicare + Part D | Not by the plan; Bridge: $50 per monthly fill (KwikPen, with conditions) | Check Plan | Standalone Part D plans may include OSA indication |
| Medicare Advantage (HMO) | Not by the plan; Bridge: $50 per monthly fill (KwikPen, with conditions) | Check Plan | Coverage varies; prior authorization may be required |
| Medicare Advantage (PPO) | Not by the plan; Bridge: $50 per monthly fill (KwikPen, with conditions) | Check Plan | Formularies vary; prior authorization may be required |
| Medicare Supplement (Medigap) | Does not cover prescription drugs—you need separate Part D | ||
What to Know About MA Plans
- Formularies vary: Not all MA plans have added Zepbound for OSA to their formulary
- Prior authorization: Plans may require PA, which can include sleep study documentation
- Cost sharing varies: Plans have different tiers, copays, and coinsurance
- Out-of-pocket limits: An MA plan's yearly out-of-pocket maximum covers medical (Part A and B) services, not prescription drugs. Drug costs count toward the separate Part D cap ($2,100 in 2026 ($2,400 in 2027)).
Open Enrollment Consideration
If your current Medicare plan doesn't cover Zepbound for OSA, you may be able to switch to a plan that does during the Annual Enrollment Period (October 15 - December 7) or Medicare Advantage Open Enrollment (January 1 - March 31). Learn more at Medicare.gov enrollment periods.
WHAT YOU'LL PAY
Cost & Alternatives for Medicare Beneficiaries
Savings Card Not Available for Medicare
Medicare beneficiaries cannot use the Zepbound Savings Card. The card's terms exclude government insurance (Not for Medicare, Medicaid, TRICARE, VA or other government insurance).[17]
The savings card (as little as $25/month) that reduces costs for commercially insured patients is not an option if you have any Medicare coverage.
If Zepbound Is Covered for OSA
If your plan covers Zepbound for the OSA indication, here's what to expect for costs in 2026:
- 2026 Part D Out-of-Pocket Cap: Medicare Part D has a $2,100 annual out-of-pocket maximum for 2026 (up from $2,000 in 2025; $2,400 in 2027). Once you reach this limit, your plan covers 100% of remaining drug costs for the year.[18]
- 2026 Part D Deductible: Maximum deductible is $615 for 2026 (up from $590 in 2025).[26]
- Tier Placement: Varies by plan. Ask your plan which tier Zepbound is on and whether you pay a copay or coinsurance
- Before OOP Cap: Your monthly cost depends on your deductible, tier and coinsurance
- After OOP Cap: $0 for the rest of the calendar year
Extra Help (Low Income Subsidy)
If you have limited income and resources, you may qualify for Extra Help, which significantly reduces Part D costs:
| 2026 Limits | Individual | Married Couple |
|---|---|---|
| Income Limit | up to 150% of the federal poverty level | up to 150% of the federal poverty level |
| Resource Limit | $18,090 | $36,100 |
With Extra Help, copays are at most $5.10 for generics and $12.65 for brand-name drugs (2026). Extra Help does not lower the $50 Bridge copay. Apply at ssa.gov/medicare/part-d-extra-help.[19]
Mounjaro Alternative for Type 2 Diabetes
Same Drug, Different Indication
If you have Type 2 Diabetes: Mounjaro (also tirzepatide, same active ingredient as Zepbound) may be covered under Medicare Part D for T2D, subject to the plan's formulary, prior authorization and exceptions process. Ask your doctor if Mounjaro is appropriate for your diabetes management. (People with type 2 diabetes can't use the Bridge.)[20]
Lilly Cares Patient Assistance
Eli Lilly's patient assistance program (Lilly Cares) is not a route to free Zepbound: Zepbound, Mounjaro and Foundayo are not on Lilly Cares’ medication list.
- Who Lilly Cares serves (for other Lilly drugs): Uninsured or on Medicare Part D/Part B, with income limits of 300–500% of the federal poverty level by drug
- Contact: Lilly Cares, 1-800-545-6962
Note: For Zepbound without coverage, LillyDirect offers cash-pay pricing at $299–$449/month—no insurance needed. See our complete cost guide for all options.
Foundayo: New Oral GLP-1 Option (April 2026)
🆕 Oral Alternative Now Available
Foundayo (orforglipron) is Eli Lilly's new oral GLP-1 medication, FDA-approved in April 2026. Unlike injectable Zepbound, Foundayo is a daily pill—no needles required.
- Self-pay price: $149–$299/month by dose via LillyDirect
- Best for: Patients who prefer pills over injections
- Medicare coverage: Foundayo is one of the drugs covered under the $50 GLP-1 Bridge (all formulations) for eligible beneficiaries
Learn more: Foundayo cost guide | Foundayo Medicare coverage
STEP-BY-STEP GUIDE
How to Check Your MA Plan's Formulary
Here's how to determine if your specific Medicare plan covers Zepbound for the OSA indication:
Visit Medicare.gov Plan Finder
Go to Medicare.gov Plan Compare and enter your ZIP code. You can search for plans or look up your current plan.
Add Zepbound to Your Drug List
In the drug search, enter "Zepbound" or "tirzepatide." The tool will show if and how the drug is covered on different plans.
Check for Coverage Notes
Look for notes about "covered indications" or "prior authorization required." Plans that cover Zepbound typically specify it's only for OSA, not weight loss.
Contact Your Plan Directly
Formularies can change, and the Plan Finder may not reflect the most current coverage. Call your plan's member services to confirm.
Call Script for Medicare Plan
"Hi, I'm calling to check coverage for a prescription medication. My Medicare ID is [NUMBER]. I need to know:
- Is Zepbound (tirzepatide) covered on my plan's formulary for obstructive sleep apnea?
- What tier is it on?
- What documentation is required for prior authorization?
- What would my out-of-pocket cost be?
- Can you send me the coverage criteria in writing?"
Pro tip: Request coverage criteria in writing and keep records of all calls, including the date, time, and representative's name.
APPEAL PROCESS
What to Do If Medicare Denies Zepbound
Bridge Denials Can't Be Appealed
The appeal steps below are for decisions by your Part D plan (for example, Zepbound for sleep apnea). If a Bridge prior authorization for weight loss is denied: No appeals process for a Bridge prior-authorization denial: your prescriber can resubmit with more information (Part D appeal rights for Part D coverage decisions still apply).
Medicare Appeals Have High Success Rates
Over 80% of Medicare Advantage prior authorization appeals succeed—yet only about 11% of patients ever appeal, according to KFF analysis of CMS data.[6] If you're denied, don't give up.
Medicare Appeal Timeline
| Appeal Level | Filing Deadline | Decision Timeline | Notes |
|---|---|---|---|
| 1. Redetermination | Within 65 days from the date on the denial notice | 7 days (72 hrs if expedited) | Reviewed by plan, not original reviewer |
| 2. Reconsideration | Within 60 days after you receive the redetermination decision | 7 days (72 hrs if expedited) | Independent review by the IRE (Independent Review Entity) |
| 3. ALJ Hearing | 60 days from reconsideration | 90 days | Requires $200+ amount in controversy (2026)[7] |
| 4. Medicare Appeals Council | 60 days from ALJ | 90 days | Reviews ALJ decision |
| 5. Federal District Court | 60 days from Council | Varies | Requires $1,960+ amount in controversy (2026)[7] |
How to Appeal a Medicare Denial
Get the Denial in Writing
Request a Coverage Determination Notice with the specific reason for denial. Common reasons include:
- "Not medically necessary"
- "Does not meet plan criteria"
- "Documentation insufficient"
- "Drug not on formulary for this indication"
Gather Supporting Documentation
Work with your doctor to compile:
- Sleep study results with AHI score ≥15
- Documentation of CPAP failure or intolerance
- Current BMI documentation
- Letter of Medical Necessity explaining why Zepbound is required
File Redetermination Request
Submit your appeal to your Medicare plan within 65 days from the date on the denial notice. Include all supporting documentation and a cover letter addressing the specific denial reason.
Escalate If Necessary
If redetermination is denied, request Reconsideration by an independent Independent Review Entity (IRE). This is an entirely new review not influenced by the plan.
For detailed appeal strategies, see our complete Zepbound appeals guide.
MEDICARE ZEPBOUND COVERAGE
Frequently Asked Questions
Basic Part D coverage does not: by law (42 U.S.C. § 1395w-102), basic Part D coverage excludes drugs used for weight loss (some enhanced plans could offer them as supplemental benefits). But Medicare can still cover it: the separate $50 Medicare GLP-1 Bridge (live since July 1, 2026) can cover the Zepbound KwikPen for weight loss outside the Part D benefit, if you meet CMS eligibility criteria and your prescriber gets prior authorization. Zepbound may also be covered under Part D for obstructive sleep apnea (OSA), a separate FDA-approved indication, subject to the plan formulary, prior authorization and exceptions process.
Potentially, yes. The FDA approved Zepbound for moderate-to-severe obstructive sleep apnea (OSA) in adults with obesity in December 2024. Since this is not a "weight loss" indication, it's not excluded by the Part D statute. However, coverage depends on whether your specific Medicare plan has added Zepbound for OSA to its formulary. Plans that cover it may require prior authorization with sleep study documentation.
Criteria vary by plan, but plans may ask for: moderate-to-severe OSA (AHI ≥ 15 events/hour) confirmed by sleep study, BMI ≥ 30 kg/m² (obese), and sometimes documentation of inadequate response or intolerance to CPAP/BiPAP therapy. The prescription should list ICD-10 code G47.33 (obstructive sleep apnea) as the primary diagnosis. Ask your plan for its criteria in writing.
Yes—as of July 1, 2026, with conditions. The Medicare GLP-1 Bridge is now live, runs outside the Part D benefit, and covers the Zepbound KwikPen for weight loss at a flat $50 per monthly fill for people with eligible Part D coverage who meet CMS's criteria. Zepbound single-dose vials and single-dose pens are not covered—only the KwikPen.
Eligibility uses three BMI tiers (Age 18+ and BMI ≥35; or BMI ≥30 with HFpEF, uncontrolled high blood pressure or CKD stage 3a+; or BMI ≥27 with prediabetes, a prior heart attack or stroke, or symptomatic PAD) and requires prescriber prior authorization. Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026. Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization.
One catch: the $50 doesn't count toward your deductible or out-of-pocket cap, and Extra Help doesn't reduce it. The Bridge runs July 1, 2026 – December 31, 2027. See our full Medicare GLP-1 Bridge guide for eligibility and how to apply.
You have five levels of Medicare appeals. Start with a Redetermination within 65 days from the date on the denial notice—the plan must respond within 7 days. If denied again, request Reconsideration by an Independent Review Entity (IRE) within 60 days after you receive the redetermination decision. Include your sleep study, AHI score, CPAP trial documentation, and a Letter of Medical Necessity.
Medicare Advantage drug plans follow the same basic Part D exclusion for weight-loss drugs, but members of MA plans with drug coverage (MA-PD) can use the Medicare GLP-1 Bridge for the Zepbound KwikPen if they meet its eligibility criteria and get prior authorization. Coverage for the OSA indication varies by plan—some MA plans have added Zepbound for OSA to their formularies while others have not. Check your specific plan's formulary using the Medicare.gov Plan Finder or call your plan directly. Plans that cover it for OSA may require prior authorization.
You may still have coverage. The Medicare GLP-1 Bridge (live since July 1, 2026) covers the Zepbound KwikPen for weight loss at $50 per monthly fill for people with eligible Part D coverage who meet CMS's criteria—no OSA diagnosis required, just the BMI-based eligibility criteria and prescriber prior authorization (Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026). See our Medicare GLP-1 Bridge guide.
If you don't qualify for the Bridge, other options include: self-pay through LillyDirect ($299–$449/month; TrumpRx.gov lists the same price), Mounjaro if you have Type 2 diabetes (same active ingredient; it may be covered under Part D for T2D, subject to the plan's formulary, prior authorization and exceptions process), or other self-pay options. See our Zepbound cost guide for all options.
YOUR PATH FORWARD
What's Next
Zepbound Coverage: Other Insurance Options
Coverage varies significantly by program type. See our guides:
- Medicaid — 13 states (as of January 2026) covered GLP-1s for obesity (state-dependent)
- TRICARE — Prior authorization: BMI ≥30, or ≥27 with a weight-related condition, after a lifestyle program and trials of other weight-loss drugs
- Humana — Medicare Advantage: weight loss through the Bridge; sleep apnea coverage depends on the plan
- UnitedHealthcare — Medicare Advantage: weight loss through the Bridge; sleep apnea coverage depends on the plan
- Aetna — Commercial coverage depends on your plan
Other GLP-1 Medications on Medicare
Medicare coverage varies by medication. Compare your options:
References
- Medical News Today. (2025). "Medicare and Zepbound: Coverage for weight loss." medicalnewstoday.com
- Medicare Prescription Drug, Improvement, and Modernization Act of 2003. 42 U.S.C. § 1395w-102(e)(2)(A). law.cornell.edu
- White House. (November 6, 2025). "Fact Sheet: President Donald J. Trump Announces Major Developments in Bringing Most Favored Nation Pricing to American Patients." whitehouse.gov
- FDA. (December 20, 2024). "FDA Approves First Medication for Obstructive Sleep Apnea." fda.gov
- Medicare Interactive / NCOA. (2025). "Maximum out-of-pocket limit." 2025 Medicare Advantage MOOP: $9,350 in-network. medicareinteractive.org; ncoa.org
- Kaiser Family Foundation (KFF). (2024). "Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023." Analysis of CMS data: 83.2% of appeals partially or fully overturned in 2022; only 11% of denials appealed. kff.org; See also: AMA commentary at ama-assn.org
- CMS. (2025). "Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026." Federal Register, December 4, 2025. 2026 thresholds: $200 for ALJ, $1,960 for Federal Court. federalregister.gov
- Wellcare. (2025). "Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage." wellcare.com
- ASPE/HHS. (2024). "Medicare Coverage of Anti-Obesity Medications." aspe.hhs.gov
- Georgetown Medicare Policy Initiative. (April 2025). "Policy options to cover anti-obesity drugs." georgetown.edu
- Medicare.gov. (2025). "Filing an appeal." medicare.gov
- Congressional Research Service. (2024). "Medicare Coverage of GLP-1 Drugs." IF12758. congress.gov
- Hernandez I, et al. (2024). "Medicare Part D Coverage of Anti-obesity Medications: A Call for Policy Change." JAMA Internal Medicine. pubmed.ncbi.nlm.nih.gov
- JAMA. (January 2025). "FDA Approves Tirzepatide as First Drug for Obstructive Sleep Apnea." jamanetwork.com
- CDC. (2024). "New Adult Obesity ICD-10-CM Codes." Codes E66.811, E66.812, E66.813 effective October 1, 2024. cdc.gov
- Malhotra A, et al. (2024). "Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity." N Engl J Med. 2024;391:1193-1205. SURMOUNT-OSA trial (NCT05412004). nejm.org
- Eli Lilly. (2025). "Zepbound Savings Card Terms and Conditions." Excludes Medicare, Medicaid, TRICARE, VA, and other government programs. zepbound.lilly.com
- CMS. (2026). "Announcement of Calendar Year (CY) 2027 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies," Table V-2 (Part D deductible and out-of-pocket threshold, 2026 and 2027). cms.gov
- Social Security Administration. "Extra Help with Medicare Prescription Drug Costs" (how to apply). 2026 resource limits and copays: CMS, "CY 2026 Resource and Cost-Sharing Limits for Low-Income Subsidy (LIS)," October 31, 2025. ssa.gov
- CRS. (2024). Medicare Coverage of GLP-1 Drugs. IF12758. "Medicare allows coverage through Part D plans for GLP-1 drugs that the FDA has approved for T2DM and CVD." congress.gov
- NCPA. (November 11, 2025). "About the Trump, Eli Lilly, Novo Nordisk deals on GLP-1 prices." ncpa.org
- Axios. (November 6, 2025). "Trump announces Medicare coverage of weight-loss drugs." axios.com
- AARP. (November 2025). "When Will the Cost of GLP-1 Weight Loss Drugs Go Down?" aarp.org
- STAT News. (November 25, 2025). "Trump administration unveils new round of Medicare-negotiated drug prices." statnews.com
- CBS News. (November 6, 2025). "Trump announces deal to lower weight loss drug prices in some cases." cbsnews.com
- Medicare.gov. (2026). "How much does Medicare drug coverage cost?" 2026 Part D deductible: $615; OOP cap: $2,100. medicare.gov
- Sleep Foundation. (December 2025). "Does Medicare Cover Zepbound for Sleep Apnea?" Note: Zepbound's OSA indication is for adults with moderate-to-severe OSA and obesity (BMI ≥30), per the FDA label. sleepfoundation.org
- CMS. (December 23, 2025). "BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model." Announced as the planned permanent framework; on April 21, 2026 CMS declined to implement it in Part D for 2027 and extended the GLP-1 Bridge through Dec 31, 2027 instead. cms.gov
- CMS. (2026). "Coming Soon: $50 Monthly GLP-1 Access for Medicare Beneficiaries" / Medicare GLP-1 Bridge — Information for Prescribers and Beneficiaries. Bridge live July 1, 2026–December 31, 2027; $50 flat monthly copay (does not count toward deductible or OOP cap; LIS does not apply); BMI-based eligibility with prescriber prior authorization. cms.gov
- Mintz. (January 5, 2026). "The BALANCE Model and a New Wave of CMS Drug Pricing Models." BALANCE waives Part D weight-loss exclusion. mintz.com
- Kiplinger. (January 5, 2026). "9 Medicare Changes to Watch in 2026." 2026 MA OOP limit: $9,250 in-network. kiplinger.com
- CMS. (June 2026). "Medicare GLP-1 Bridge — Information for Pharmacies." Covered drugs and forms: Wegovy (injection and tablets) and Foundayo; Zepbound KwikPen only—single-dose vials and single-dose pens not covered. cms.gov
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