Editor’s Note: This article is part of MOAA’s 2024-25 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Association Member Benefits Advisors (AMBA). A version of the guide appeared in the November 2024 issue of Military Officer magazine. 

New developments in the pharmaceutical industry provide hope for patients with chronic conditions and questions about TRICARE coverage and affordability.

TRICARE can be slow to adapt coverage policy to new technology and evolving treatment protocols, but nearly all drugs are covered by the TRICARE Pharmacy Program once they’ve been FDA-approved. The few exceptions include delayed coverage for some infusion medications considered for coverage under the TRICARE medical benefit.

For chronic weight management, TRICARE covers both Wegovy and Zepbound but with step therapy and prior-authorization requirements.

Step therapy policies require patients to try less expensive medications before “stepping up” to more expensive options. These policies are intended to direct medical providers and patients — who might not have visibility on prescription drug prices — to the most cost-effective treatments.

[UPDATED MONTHLY: MOAA's TRICARE Toolkit]

For both Wegovy and Zepbound, TRICARE prior authorization requires adult patients to:

• Have a BMI greater than or equal to 30 — or a BMI greater than or equal to 27 with additional risk factors (e.g., hypertension, sleep apnea).
• Engage in a trial of behavioral modification and dietary restriction for at least six months and fail to achieve desired weight loss.
• First try and fail (or have contraindications for) one of four other prescription drugs approved for weight loss.
• Remain engaged in behavioral modification and a reduced calorie diet through the course of therapy.

You can find specifics on TRICARE prior authorization requirements using the TRICARE Formulary Search tool. Once you’ve looked up the specific medication, click on “covered with limitations” and then “prior authorization form (pdf)” to see detailed requirements for coverage approval.

Once approved, TRICARE beneficiaries have a $38 copay for Wegovy and a $38 copay for Zepbound for a 90-day supply via the TRICARE Pharmacy Home Delivery program (as of this writing).

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Health care providers may prescribe diabetes medications, Ozempic and Mounjaro, off-label to help people without diabetes lose weight, but the medications are not FDA-approved for this purpose. While TRICARE covers Ozempic and Mounjaro to treat Type 2 diabetes — with prior authorization — TRICARE and many other health plans will not approve Ozempic and Mounjaro prescribed for off-label weight management use.

Health Plans and Medicare

Commercial health plan coverage for weight loss drugs remains inconsistent and continues to evolve. High costs and high demand for weight loss drugs have left payers struggling to balance coverage considerations with budget impacts.

A 2023 study by Tufts Medical Center for the Evaluation of Value and Risk in Health found commercial health plans are restricting access to weight loss drugs and coverage requirements vary considerably.

Medicare is currently prohibited by law from covering medications specifically used for weight management. However, a path for Medicare coverage opened recently when the FDA approved Wegovy to reduce risks associated with cardiovascular disease among those overweight or obese. The Centers for Medicare & Medicaid Services has issued a memo indicating Medicare Part D (prescription drug plans) can include Wegovy on their formularies given the new FDA approval for cardiovascular health benefits.

Commercial health plans often follow coverage policies established by Medicare, so there might be expanded and more consistent coverage of weight loss medications by commercial and employer-sponsored plans. As coverage for weight loss drugs expands, enrollees in commercial health plans and Medicare Part D are likely to face higher monthly premiums to offset the high costs associated with these medications.

MOAA will continue to monitor weight loss medication coverage policies to ensure TRICARE evolves to keep up with commercial plan benchmarks and other government payers. Access to new medications and treatments must be part of the world-class TRICARE benefit our servicemembers and retirees have earned.