Medicare is expected to start covering Zepbound in 2026 through a pilot program. Learn more about the new program

New therapies for chronic weight management are prompting major shifts in U.S. coverage policy. A Medicare demonstration slated for 2026 is expected to test Part D access to Zepbound within defined clinical and program safeguards. While official guidance is still forthcoming, the outline below describes how pilots of this kind generally work, what eligibility criteria are commonly used, and how beneficiaries can prepare to verify participation in their area.

This article is for informational purposes only and should not be considered medical advice. Please consult a qualified healthcare professional for personalized guidance and treatment.

What is the Medicare Zepbound pilot and how will it work?

A Medicare pilot typically operates as a time-limited demonstration overseen by the Centers for Medicare & Medicaid Services (CMS), often through the Center for Medicare and Medicaid Innovation. The Zepbound pilot is expected to evaluate whether structured coverage—paired with clinical monitoring and behavioral support—improves outcomes for eligible beneficiaries. Participation is usually limited to certain Part D plans or Medicare Advantage plans with drug coverage that opt into the model, and it may be available only in selected regions.

Expect common utilization safeguards used in similar pilots. These may include prior authorization to confirm clinical need, documentation of participation in lifestyle or nutrition counseling, prescriber qualifications (such as evaluation by a clinician experienced in weight-related care), and periodic reassessment to confirm that treatment remains appropriate. Plans may be asked to report on outcomes and safety. Coverage parameters, including dosing, duration limits, and coordination with local services, are typically spelled out in plan materials once finalized.

Who qualifies for Medicare Zepbound coverage in 2026?

Final criteria will be defined through CMS guidance and participating plan policies. In comparable programs, eligibility generally requires active Medicare Part D or a Medicare Advantage plan with prescription coverage, a diagnosis aligned with the drug’s FDA labeling, and documentation of medical necessity. For anti-obesity medications, plans often use body mass index thresholds (for example, BMI of 30 or higher, or 27 or higher with certain weight-related conditions) and may require records of prior lifestyle interventions.

Other typical considerations can include assessment of coexisting conditions, medication contraindications, and how Zepbound interacts with current therapies. Some plans may require enrollment in structured behavioral or nutritional support alongside the medication. Because Medicare pilots can vary by plan and geography, availability may differ in your area. Beneficiaries should also expect formulary-specific rules, such as step therapy, refill checks aligned with follow-up visits, and ongoing review of benefits and risks.

How to enroll in the Medicare Zepbound pilot program

Enrollment usually depends on whether your Part D or Medicare Advantage plan decides to participate. Ahead of the 2026 plan year, review plan documents and the Medicare Plan Finder to see if the pilot is offered by plans available in your area. If you are considering switching plans, compare formularies and utilization rules during the Annual Enrollment Period preceding 2026, and confirm participation directly with the plan’s member services.

Next, speak with your clinician about whether Zepbound is appropriate for your health profile. You may be asked to provide documentation such as BMI measurements, relevant diagnoses, prior attempts at lifestyle modification, and a treatment plan that may include nutrition and activity supports. If prior authorization is required, your prescriber or clinic typically submits the request. Keep copies of all paperwork, track approvals and denials, and use your plan’s appeal process if coverage is initially declined. Pharmacies in your area can also confirm dispensing requirements and stock availability once coverage is active.

What to expect on timing: Pilot details are typically finalized in advance of the plan year, with plans signaling participation in their benefit materials. Implementation often includes staged rollout and ongoing data collection. Beneficiaries should monitor plan updates, review Evidence of Coverage documents, and verify requirements before filling a prescription.

Benefits and limitations to consider: A pilot can expand access for eligible beneficiaries while building evidence on outcomes and safety. At the same time, coverage may be limited to certain plans or regions, and continued approval can depend on adherence, clinical response, and documented follow-up. Supply constraints, changes in labeling, or new safety information can also influence availability and plan policies over time.

Conclusion The anticipated 2026 Medicare pilot for Zepbound aims to test a structured approach to coverage within selected plans, using tools such as prior authorization, clinical monitoring, and integration with behavioral support. Because details are still being finalized, beneficiaries should watch for plan announcements, review documentation requirements with their clinicians, and confirm whether participating options are available in their area.