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Why Medicare Won’t Cover GLP-1 Drugs for Weight Loss
Jared Dashevsky, MD
April 13, 2025 • Estimated Reading Time: 10 minutes
GRAND ROUNDS
Medicare GLP-1 Coverage? Hard Stop.
The Trump administration just slammed the brakes on a major Biden-era push: expanding Medicare and Medicaid coverage for obesity drugs like Wegovy (semaglutide) and Zepbound (tirzepatide).
Didn’t see that coming?
Actually—I did.
“CMS GLP-1 Coverage Falls Through” was prediction #7 in my 16 Healthcare Predictions for 2025, published back in December.
In this article, I’ll unpack what CMS originally planned to do, what these GLP-1s are currently approved for, and how the reversal impacts patients, physicians, and the broader health system.
The Deets
In November 2024, the Biden administration proposed a major shift: allowing CMS to cover GLP-1s like Wegovy and Zepbound for obesity treatment. The move would’ve expanded access for an estimated 7 million Americans on Medicare and Medicaid.
Today, just 13 states offer Medicaid coverage for GLP-1s specifically for obesity—most states only cover them for diabetes.
But covering GLP-1s for weight loss remains controversial. The roadblock? The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which explicitly prohibits coverage of drugs for anorexia, weight loss, or weight gain. Because of that, physicians have relied on workaround medications like topiramate, bupropion, and naltrexone.
Had the Trump administration moved forward with Biden’s plan, the price tag would’ve been steep: $40 billion over the next decade—$25 billion from Medicare and $15 billion from Medicaid.
What Are GLP-1s Actually Approved For?
The FDA has approved the newest GLP-1s—semaglutide by Novo Nordisk and tirzepatide by Eli Lilly—for multiple indications. I outline them below:
Semaglutide Approvals:
Glycemic control for those with type 2 diabetes.
Chronic weight management in adults with obesity or overweight with at least one weight-related condition (such as high blood pressure, type 2 diabetes, or high cholesterol)
Reduce the risk of heart attack, stroke, or death in adults with type 2 diabetes and known heart disease.
Reduce risk of CKD progression in patients with type 2 diabetes.
Tirzepatide Approvals:
Glycemic control for those with type 2 diabetes.
Chronic weight management in adults with obesity or overweight with at least one weight-related condition (such as high blood pressure, type 2 diabetes or high cholesterol)
Treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Dashevsky’s Dissection
We’re witnessing an accessibility crisis with GLP-1s.
At baseline, these remarkably effective medications are tough to get unless you have type 2 diabetes. For patients with T2DM? No problem. I rarely run into issues prescribing them. But for anyone else? It’s a battle.
Direct-to-consumer startups like Noom, Found, and Hims & Hers jumped in to fill that gap, many pivoting to prescribe compounded GLP-1s for under $200 a month—a fraction of the out-of-pocket cost for the brand-name alternatives.
But now? Compounding pharmacies can no longer produce semaglutide or tirzepatide.
And just like that—we take ten steps back on access.
For patients with obesity or overweight, these high barriers are a real detriment to health. And for us as physicians, it’s frustrating. We see patients who are incredibly motivated to lose weight, but can’t access the very medications that could help them succeed. We write appeal letters, but they rarely go anywhere.
Even when we do manage to get GLP-1s approved, adherence becomes the next hurdle.
I’ve seen it firsthand: patients lose a significant amount of weight, then stop the medication about a year in. Anecdotally, this felt like a trend. Now we’ve got data to back it up….
A recent retrospective cohort study looked at GLP-1 adherence in patients with obesity and with/without diabetes:
Those with T2DM:
46.5% discontinued by year one
64.1% discontinued by year two
Those without T2DM:
64.8% discontinued by year one
84.4% discontinued by year two
So yes—access is a problem. But so is adherence.
And underneath it all, cost continues to be the elephant in the room.
These drugs are clinically effective—but far from cost-effective. That’s a big reason why the Trump administration is pulling back on CMS coverage.
A recent JAMA study ran the numbers, and the findings weren’t pretty:
Tirzepatide’s ICER was $197,023/QALY
Semaglutide’s ICER was $467,676/QALY
So what does that mean?
ICER, or incremental cost-effectiveness ratio, tells us how much more we’re spending to gain one extra year of life in good health—measured as a QALY, or quality-adjusted life year. It’s the gold standard for measuring value in healthcare.
And in the U.S., the widely accepted threshold for cost-effectiveness is $100,000 per QALY. These GLP-1s are powerful, but at current prices, we’re paying far more than what the health system considers good value.
My take? It’s a shame the Trump administration won’t expand CMS coverage for these drugs, it’s not irrational. The cost-effectiveness data just doesn’t support widespread coverage right now. As clinicians, we see the clinical benefit every day. But from a policy and budget standpoint, the math simply doesn’t add up—yet.
In summary, while GLP-1s like semaglutide and tirzepatide are clinically effective and increasingly in demand, access remains limited due to regulatory, financial, and practical barriers. The Biden administration’s plan to expand CMS coverage was a step forward—but with ICERs far exceeding accepted cost-effectiveness thresholds, the Trump administration’s decision to halt that effort, while disappointing, isn’t without justification. Until prices drop or value improves, broader public coverage remains a tough sell.
COMMUNITY POLL
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