Does Medicare Cover Tirzepatide? Criteria, Copay, How to Appeal
Medicare Part D covers GLP-1s for type 2 diabetes but not for weight loss alone. The Medicare GLP-1 Bridge covers Zepbound for weight loss at $50 a month from July 1, 2026 to December 31, 2027, if you meet its BMI rules.
- Medicare GLP-1 Bridge copay
- $50 a month
- Bridge runs
- July 1, 2026 to December 31, 2027
- tirzepatide in the Bridge
- Some
- Part D for weight loss alone
- Not covered
Zepbound key facts
The half-life is 5 to 6 days. At 5.5 d, half is gone, while about 3% remains by the time five half-lives (27.5 d) are done.
In SURMOUNT-1 over 72 weeks, 20.9% of body weight was lost, against 3.1% on placebo.
Monthly prices in US dollars: the list price and self-pay offers, each taken from the manufacturer's price page.
Sources: FDA label (DailyMed), Eli Lilly 1 2, cnbc.com.
Does Medicare cover tirzepatide?
- Part D and weight loss on its own
- Part D can cover use for diabetes or cardiovascular disease
- Your plan may cover it for fatty liver, sleep apnea or type 2 diabetes
Sources: pricinginfo.lilly.com, mounjaro.lilly.com, GoodRx, zepbound.lilly.com.
The published policy
- Bridge starts: July 1, 2026
- Bridge ends: December 31, 2027
- Copay: Medicare GLP-1 Bridge, $50 per month
- Included in the Bridge: Foundayo, Wegovy, Zepbound KwikPen
- Vials and single-dose pens are not covered by the Bridge
- Counts toward your Part D deductible: No
medicare.gov posts the policy itself, so read it there.
Sources: medicare.gov, humana.com, CMS.
Prior authorization checklist
- Your BMI by itself: 35 or higher, with no other condition needed
- Heart or kidney condition plus a BMI of 30 or above: together with heart failure, uncontrolled blood pressure, or CKD 3a+
- With a condition and a lower BMI: a BMI of 27 or above plus prediabetes, PAD, a previous heart attack, or a stroke
- Getting approval through prior authorization
- Records: what to include: the diet and activity program that you have tried before, your height and weight as measured, and your weight-related conditions.
- Your prescriber files it, not you: the prescriber submits the prior authorization.
Source: medicare.gov.
Appealing a denial
| Denial reason | What to send or ask |
|---|---|
| Criteria not met | Have your prescriber resubmit the request with your measured BMI and each weight-related condition listed in your chart. The rule requires a BMI of 35, or 27 when you have a weight-related condition. |
| The drug is not on the plan's list | Ask for a formulary exception, and also ask which GLP-1 your plan prefers as an alternative. |
- Ask your Part D plan for a coverage determination, or for an exception when the drug is not on its list.
- If the answer is no, request a redetermination from the plan. Your prescriber can also send a statement to support it.
- Should that fail, an outside, independent reviewer receives the appeal.
State and plan differences
Medicare Advantage plans that include drug coverage follow the same rules. Humana is one such plan: for every 30-day supply it lists a Bridge copay of $50.
Because every Part D plan has a separate drug list and copay tiers, diabetes-use copays differ from plan to plan.
If you have Medicare and Medicaid, your state's Medicaid rules apply as well: Does Medicaid Cover Tirzepatide? Criteria, Copay, How to Appeal.
Source: humana.com.
Other choices when coverage says no
Sources: pricinginfo.lilly.com, mounjaro.lilly.com, GoodRx, zepbound.lilly.com.