Under current law, Medicare’s prescription drug benefit (Part D) excludes “agents when used for anorexia, weight loss, or weight gain”. This exclusion has prevented Medicare from covering obesity medications and has allowed Medicaid plans to opt out of providing such coverage.

For more than a decade, the OAC has pursued both legislative and regulatory pathways to expand access to comprehensive obesity care. Advocates have urged Congress to address this exclusion by passing the Treat and Reduce Obesity Act (TROA). Simultaneously, discussions have taken place with the Centers for Medicare and Medicaid (CMS) and various Administrations about a regulatory solution to provide coverage for obesity medications.

New Regulatory Action

On November 26th, the White House announced a Proposed Rule to expand coverage for obesity medications under Medicare and Medicaid.

Highlights of the Proposed Rule:

  • Reinterpreting Exclusionary Language: The rule proposes that medications used for weight loss or chronic weight management for treating obesity would be covered.
  • Flexibility in Defining Obesity: While the rule does not define obesity, it permits Part D plans to establish criteria for prior authorization. However, these criteria cannot be more restrictive than the prescribing indication criteria.
  • Recognition of Obesity as a Chronic Disease: The rule acknowledges obesity as a chronic condition, emphasizing that patients will require ongoing therapy for effective treatment and therefore patients will need ongoing therapy for proper treatment.
  • Coverage Timelines: Medicare coverage for obesity medications would begin in January 2026. Medicaid coverage could start 60 days after the final rule is published but no later than January 2026.

Next Steps

A 60-day public comment period allows individuals to provide feedback on the Proposed Rule. Public comments are essential in shaping policy, amplifying voices and driving meaningful change.

The OAC hosted two information sessions to explain the Proposed Rule and guide individuals on submitting a Public Comment. Click Here to watch the latest session.

To submit a Public Comment, Click Here.

Resources:

The voices and efforts of obesity care advocates have been instrumental in reaching this significant milestone. We encourage individuals living with obesity, healthcare providers and organizations to submit comments on the Proposed Rule.

OAC Members and supporters are especially urged to share how this policy change would impact them personally or professionally. Your voice can help ensure access to obesity care for millions of Americans!