CMS Excludes Obesity Drugs from Medicare Coverage Amid Cost Concerns
Eli Lilly has publicly criticized the Centers for Medicare and Medicaid Services (CMS) for excluding obesity medications such as Zepbound and Wegovy from Medicare Advantage and Part D coverage for 2026. This decision restricts access to obesity management drugs, impeding healthcare providers’ ability to select appropriate treatments for patients with obesity and related conditions like sleep apnea. Medicare currently does not cover any drugs solely indicated for weight loss, leading manufacturers to seek alternative FDA-approved indications to gain coverage, such as obstructive sleep apnea for Zepbound.
The Biden administration had proposed a rule in November 2024 aimed at recognizing obesity as a chronic disease to facilitate Medicare Part D coverage of anti-obesity medications without requiring label expansions. However, the CMS’s latest ruling maintains the status quo but leaves open the possibility for future policy adjustments based on cost-benefit evaluations. CMS highlights that coverage of these therapies is not appropriate at this time but may be reconsidered in the future.
Cost considerations remain a central factor in the CMS decision, as a Congressional Budget Office report estimates a potential $35 billion increase in federal spending on obesity drugs under Medicare between 2026 and 2034. The CBO also notes that the resulting health savings would be relatively small. This dynamic illustrates the ongoing tension between expanding access to obesity treatments and managing governmental healthcare expenditures.
The exclusion of obesity drugs from Medicare coverage underscores broader challenges in payer-driven limitations affecting chronic disease management. These policy decisions affect not only patients living with obesity but also those impacted by comorbid conditions. The controversy reflects the evolving regulatory landscape and fiscal constraints shaping Medicare’s formulary decisions.
Stakeholders in the health insurance and pharmaceutical sectors will need to monitor future CMS policy developments closely, as shifts in coverage rules could influence market access and treatment paradigms. The debate emphasizes the intersection of regulatory approval, payer reimbursement, and clinical care strategies in the management of obesity within the Medicare population.