All 2026 dates on sale. Register before December 31!
Recent headlines about Medicare GLP-1 price cuts for medications like Ozempic and Wegovy have generated significant patient interest and questions in weight loss practices across the country. As providers, understanding the details behind these announcements is essential for accurate patient counseling and managing expectations.
Two distinct federal initiatives are driving these changes: the Inflation Reduction Act’s drug price negotiation program (effective January 2027) and a voluntary manufacturer pilot program (starting mid-2026).
Each has different implications for patient access and cost. Confusing the two can lead to disappointed patients and administrative headaches for your practice.
At IAPAM, we continue to follow developments in GLP-1 weight loss training and education, helping physicians navigate the rapidly evolving landscape of obesity medicine and understand the complex reimbursement policies that affect their practices.
According to reporting by NBC News on November 25, 2025, the Centers for Medicare & Medicaid Services announced negotiated prices for 15 high-cost drugs under the Inflation Reduction Act’s drug price negotiation program. Among these medications are Ozempic®, Wegovy®, and Rybelsus®—all GLP-1 agonists manufactured by Novo Nordisk.
It is critical to understand what this negotiated price represents. As explained in the Kaiser Family Foundation’s (KFF) analysis published on November 26, 2025, this $274 figure is the price Medicare will pay to manufacturers, not the patient copay.
Patient out-of-pocket costs will vary based on their specific Part D plan structure, deductibles, and whether they have reached catastrophic coverage.
The negotiated price affects the plan’s cost basis, which may reduce patient copays, but does not guarantee a specific out-of-pocket amount for individual patients.
Reuters reported on November 25 that the 2027 savings of 36% on net spending represents an improvement over the first round of Medicare drug price negotiations, which achieved 22% savings according to Goldman Sachs estimates.
The 2027 price reduction does not modify the fundamental coverage restrictions that have been in place for over two decades.
As detailed in AARP’s coverage guide updated on November 21, 2025, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 explicitly prohibits Medicare Part D plans from covering medications prescribed primarily for weight loss as part of the standard benefit.
This restriction was implemented following concerns about diet medications in the late 1990s, including the fen-phen scandal.
Juliette Cubanski, deputy director of the program on Medicare policy for KFF, explained in the organization’s analysis that “there was skepticism of weight loss medications that existed at the time, and a sense that obesity was more of a behavioral problem than a medical condition.”
The bottom line: Patients seeking GLP-1 medications solely for weight management without qualifying comorbidities will not have coverage under the 2027 price negotiation program, regardless of how low the negotiated price becomes.
Medicare Part D currently covers GLP-1 agonists only when prescribed for FDA-approved indications other than obesity alone.
The FDA approved Wegovy® for cardiovascular risk reduction in adults with established cardiovascular disease who are also overweight in March 2024, which opened the door for Medicare coverage in that specific population. Similarly, Wegovy®’s approval for MASH in August 2025 created another covered indication.
However, obesity as a standalone diagnosis remains excluded from standard Medicare Part D coverage.
On November 6, 2025, President Trump announced agreements with pharmaceutical manufacturers Eli Lilly and Novo Nordisk to dramatically reduce GLP-1 prices and expand Medicare coverage for obesity. According to the White House fact sheet released that day, this represents “the most significant actions ever taken by our Federal government to lower prescription drug prices.”
The agreements establish a voluntary pilot program that will begin in mid-2026, representing the first time Medicare will cover GLP-1 medications specifically for obesity, though only for patients meeting defined comorbidity criteria.
The White House stated that “the Medicare prices of Ozempic, Wegovy, Mounjaro, and Zepbound will be $245, less than half the prices proposed by the Biden Administration on such drugs. State Medicaid programs will also have access to these medications at these prices.”
CNBC reported on November 6, 2025, that “Medicare will start covering obesity drugs for some patients for the first time starting mid-2026, a long-awaited move that could broaden the market for the medicines and spur more private insurers to cover them.”
A senior administration official explained the rationale to CNBC: “We are constraining the access for patients that will benefit clinically from it, we’ve worked very hard to strike a balance between broad access that just makes sure to capture patients that will benefit clinically.”
Documentation of these qualifying conditions will be essential for coverage approval. According to Eli Lilly’s press release on November 6, 2025, “starting as early as April 1, 2026, Medicare beneficiaries will pay no more than $50 per month for Zepbound (tirzepatide).”
Monitor updates from CMS as implementation details for both programs may be refined as launch dates approach.
The Kaiser Family Foundation noted in their analysis that a third round of Medicare drug price negotiations is expected to begin in February 2026, with 15 additional drugs to be selected.
Policy in this area continues to evolve, and staying current with authoritative sources such as KFF, AARP, and CMS will help you provide accurate guidance to patients.
Stacie Dusetzina, a health policy professor at Vanderbilt University, noted in NBC News’ coverage: “The price negotiations look very reasonable to me. It should hopefully provide some relief for taxpayers and beneficiaries in the long run.”
However, she also pointed out that the $274 negotiated price is higher than the $245 government payment in the pilot program, highlighting the complexity patients and providers must navigate.
Sean Sullivan, a professor of pharmacy at the University of Washington, observed in Reuters’ reporting that the Medicare negotiated prices may have broader market implications: “These prices are going to come down below the existing net prices.
There will be some real savings. All of the other payers can see them. What is going to stop them from asking manufacturers for that same price?”
This suggests that private insurers may also seek similar pricing, potentially benefiting your non-Medicare patients in the future.
The recent Medicare announcements represent two separate initiatives with distinct timelines and eligibility requirements.
The 2027 Inflation Reduction Act price negotiation reduces costs for patients with currently covered indications such as diabetes and cardiovascular disease.
The 2026 pilot program expands coverage to a specific subset of patients with obesity and qualifying comorbidities.
These are not interchangeable programs, and patients often conflate the two based on media coverage.
When patients express excitement about “cheaper GLP-1s,” verify both coverage eligibility and the specific program that applies to their clinical situation.
Price reductions are only meaningful if the medication is covered for the patient’s indication under their Medicare Part D plan.
For your practice, the key is to cut through the headlines and help patients understand what these changes actually mean for their individual circumstances.
Not every patient will benefit, and those who do will benefit in different ways depending on their diagnoses, BMI, and which program they qualify for.
Accurate patient counseling requires:
Get trained in glp-1s and FDA-approved medical weight management treatments. Learn from the comfort of your home or office with our comprehensive online Certified Medical Weight Management Provider™ (CWMP) program.
References
The information in this article is based on the following sources:
Contains: Emerging trends, expert discussions, recommendations, technique comparisons… and more!