Medicare Part D does not treat a weight loss drug like other drugs. Federal law leaves agents used for weight loss outside the definition of a covered Part D drug, so a plan is not choosing to exclude it. What the plan still decides is whether the prescription is written for something else it covers.
By the Covered Weight editorial team · Updated Aug 7, 2026. Research and sourcing by Evan Reid.
The answer starts with a definition, not with a formulary
A drug is not a covered Part D drug when it falls in a class the Medicaid statute lets a state program exclude or restrict, and agents used for weight loss are named in that list. The exclusion sits in the definition, which is why a Part D plan is not choosing to leave the drug off.
That is why calling the plan and asking it to add the drug rarely goes anywhere. The plan is working inside a definition somebody else wrote, and the definition is where the answer lives.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 7, 2026
Such term does not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title
Excerpt ends before the sentence continues with the carve-backs for smoking cessation agents and barbiturates. The en dash inside the cross-reference is the character the source prints. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 7, 2026
The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.
Two consecutive paragraphs joined by a single space: the (d)(2) lead-in and item (A). No characters were changed. Cited here for the Part D question rather than the Medicaid one, because the Part D definition adopts this list by cross-reference.
The list names a use, not a drug
The list names agents when used for anorexia, weight loss, or weight gain, so what it excludes is a USE rather than a molecule. The same drug can be a covered Part D drug when the prescription is written for a different condition the plan covers it for, which makes the useful question one about the indication on the prescription rather than about the brand.
Nothing here is a suggestion about what a prescription should say. It is a statement about how the rule is written, and the reason it matters is that a reader who hears the drug is banned from Medicare has heard something the rule does not say.
When the drug is simply not on the formulary
An exception asks the plan to cover a drug that is not on its formulary. The rule turns on the prescriber's supporting statement, so the request that arrives without one has started a clock the plan can run out. A request about a drug the definition excludes altogether is a different question from a request about a drug the plan simply did not list.
Who may file
The enrollee, the enrollee's representative, or the prescribing physician or other prescriber acting on the enrollee's behalf.
The clock on the supporting statement
14 calendar days
From receipt of the exceptions request.
The window the rule allows before the plan must decide anyway. It is the plan's deadline rather than the reader's, and it is the reason a supporting statement sent late can arrive after the decision it was meant to support.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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If a supporting statement is not received by the end of 14 calendar days from receipt of the exceptions request, the Part D plan sponsor must notify the enrollee
The third sentence of paragraph (b), trimmed at the 200-character budget before it repeats the outer-limit wording and the 72-hour figure. A separate key from part_d_coverage_determination_standard_42cfr423_568b because the two facts are different sentences doing different work, and one key must never carry two facts a reader could check separately.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
The Part D plan sponsor must grant an exception whenever it determines that the drug is medically necessary, consistent with the physician's or other prescriber's statement
Trimmed at the 200-character budget before the sentence continues "under paragraph (b)(5) of this section, and that the drug would be covered but for the fact that it is an off-formulary drug". The trailing clause is the one that keeps this rule inside the covered-drug definition rather than around it.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
An enrollee, the enrollee's representative, or the prescribing physician or other prescriber (on behalf of the enrollee) may file a request for an exception.
The whole of item (b)(4), verbatim.
The route when the plan says no, and what each step is allowed to take
These windows are set by federal regulation, so they are the same in every state. Each figure below prints in the unit the rule uses, and the section it was read from sits beside it.
Step 1
Coverage determination
The plan's first answer on whether it will cover the drug. A request for an exception to the formulary is one kind of coverage determination, which is why an exception and a first denial run on the same clock.
Filed by: The enrollee, the enrollee's representative, or the prescriber, with the plan.
Time to file
The rule sets none for this step.
Time to decide
72 hours
From receipt of the request, or for an exception request receipt of the prescriber's supporting statement.
The rule sets an outer limit and requires the plan to answer as quickly as the enrollee's health condition requires, so this is a ceiling rather than a normal wait.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its determination as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receipt of the request
Mid-sentence excerpt of the first sentence of paragraph (b), which opens "When a party makes a request for a drug benefit, the Part D plan sponsor must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate)". Trimmed only to stay inside the 200-character budget; no characters were changed.
Time to decide when urgent
24 hours
From receipt of the request, or for an exception request receipt of the prescriber's supporting statement.
Applies once the plan has approved a request to expedite. The same outer-limit wording governs, so the clock is a ceiling and not a schedule.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its decision, whether adverse or favorable, as expeditiously as the enrollee's health condition requires, but no later than 24 hours after receiving the request
Mid-sentence excerpt of the first sentence of paragraph (a), which opens "Except as provided in paragraph (b) of this section, a Part D plan sponsor that approves a request for expedited determination must make its determination and notify the enrollee".
Step 2
Redetermination by the plan
The first appeal. It goes back to the same plan and asks it to look again, and it is the step that has to finish before anyone independent will take the case.
Filed by: The enrollee, or the prescriber acting on the enrollee's behalf, with the plan that issued the denial.
Time to file
60 calendar days
From receipt of the written coverage determination notice.
The rule allows the plan to extend this window for good cause shown. Read the notice for the address the request has to reach, because the filing date is the date it arrives there.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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a request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice
Excerpt of the first sentence of paragraph (b), which opens "Except as provided in paragraph (c) of this section" and continues past the budget with the at-risk determination cross-reference. Paragraph (c) is the good-cause extension the record's note names.
Time to decide
7 calendar days
From the date the plan receives the request.
This is the window for a request about a drug benefit. A request about paying back money already spent is a different rung of the same rule and runs longer.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its redetermination as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days from the date it receives the request for a standard redetermination
Mid-sentence excerpt of item (a)(2), which opens "If the Part D plan sponsor makes a redetermination that affirms, in whole or in part, its adverse coverage determination or at-risk determination, it must notify the enrollee in writing". Paragraph (b) sets a different window for a request to be paid back for a drug already bought, which is why the record's note names the distinction.
Time to decide when urgent
72 hours
From the plan receiving the request.
Applies once the plan has approved a request to expedite the appeal. The request to expedite may be made orally.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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notice of its decision as expeditiously as the enrollee's health condition requires but no later than 72 hours after receiving the request
Mid-sentence excerpt of item (d)(1), which opens "A Part D plan sponsor that approves a request for expedited redetermination must complete its redetermination and give the enrollee (and the prescribing physician or other prescriber involved, as appropriate),".
Step 3
Reconsideration by an independent review entity
The first review by somebody outside the plan. The entity holds a contract with the federal program rather than with the plan, and the plan's written redetermination is what names it.
Filed by: The enrollee, or the prescriber acting on the enrollee's behalf, in writing with the independent review entity named in the plan's written redetermination.
Where the denial rests on medical necessity, the rule requires the reconsideration to be made by a physician with expertise appropriate for the services at issue. That physician does not have to be in the same specialty as the prescriber.
Time to file
60 calendar days
From receipt of the written redetermination by the plan.
The request has to be in writing. For a drug that is not on the formulary the rule also requires the prescriber to have determined that the formulary alternatives would not work as well or would cause harm, so this rung is not reachable on the paperwork alone.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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must file a written request for reconsideration with the IRE within 60 calendar days after receipt of the written redetermination by the Part D plan sponsor
Excerpt of the third sentence of paragraph (a), whose subject is "The enrollee, or the enrollee's prescribing physician or other prescriber (acting on behalf of the enrollee)". Paragraph (c) adds the condition the record's note names for a drug that is not on the formulary.
Time to decide
7 calendar days
From the date the entity receives the request.
The rule gives the entity no more time than the plan had at the rung below, by pointing at the same deadlines rather than setting its own. Two sources carry it: one quote imports the deadlines and the other is the section that prints the figure.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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must not exceed the deadlines applicable in § 423.590, including those deadlines that are applicable when a request for an expedited reconsideration is received and granted.
The close of paragraph (d), whose sentence opens "The independent review entity must conduct the reconsideration as expeditiously as the enrollee's health condition requires but". The section number sign is the character the source prints. This is a cross-reference rather than a figure, which is why the two durations it backs carry 423.590's numbers and cite 423.600(d) as the rule that imports them.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its redetermination as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days from the date it receives the request for a standard redetermination
Mid-sentence excerpt of item (a)(2), which opens "If the Part D plan sponsor makes a redetermination that affirms, in whole or in part, its adverse coverage determination or at-risk determination, it must notify the enrollee in writing". Paragraph (b) sets a different window for a request to be paid back for a drug already bought, which is why the record's note names the distinction.
Time to decide when urgent
72 hours
From the entity receiving the request.
The same cross-reference carries the expedited window, so an expedited reconsideration runs on the plan-level expedited clock. The figure is printed at the section the second source names, not at this one.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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must not exceed the deadlines applicable in § 423.590, including those deadlines that are applicable when a request for an expedited reconsideration is received and granted.
The close of paragraph (d), whose sentence opens "The independent review entity must conduct the reconsideration as expeditiously as the enrollee's health condition requires but". The section number sign is the character the source prints. This is a cross-reference rather than a figure, which is why the two durations it backs carry 423.590's numbers and cite 423.600(d) as the rule that imports them.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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notice of its decision as expeditiously as the enrollee's health condition requires but no later than 72 hours after receiving the request
Mid-sentence excerpt of item (d)(1), which opens "A Part D plan sponsor that approves a request for expedited redetermination must complete its redetermination and give the enrollee (and the prescribing physician or other prescriber involved, as appropriate),".
This reads the Part D coverage determination and appeal clocks for all 51 jurisdictions. These rules reach the Part D drug benefit. A service billed under Part A or Part B runs under a different set of rules that this page does not read.
The route does not end at the independent review entity. Levels above it exist, and this record has read none of their rules, so it describes none of them. The decision you receive from the entity names what comes next and what the window for it is, and that notice is the authority for your case rather than this page.
What this page does not answer
This record describes the federal Part D drug benefit. It does not describe what any individual plan's formulary covers, and it does not reach a service billed under Part A or Part B, where a different set of rules applies.
Start by finding out which document governs your plan
Everything else follows from it. A state program publishes its own rules. A marketplace plan is measured against a state benchmark. An employer plan that pays claims out of the employer's own funds sets its own rules, and no state rule reaches it.
Why is a weight loss drug treated differently under Part D?
Because of where the rule sits. Federal law defines what can count as a covered Part D drug, and that definition leaves out the classes a state Medicaid program is allowed to restrict. Agents used for weight loss are named in that list. So the drug is outside the definition before any plan looks at it, which is different from a plan choosing to leave something off its formulary.
Does that mean the drug can never be paid for under Part D?
No, and this is the part most often read wrongly. The list names agents when used for anorexia, weight loss, or weight gain, so it describes a use rather than a molecule. The same drug can be a covered Part D drug when the prescription is for a different condition the plan covers it for. The question worth asking names the indication rather than the brand.
What is a coverage determination, and how is it different from an appeal?
A coverage determination is the plan first answer on whether it will pay. An appeal comes after that answer is no. A request for an exception to the formulary is one kind of coverage determination, which is why an exception request and a first denial run on the same clock.
Who has to write the supporting statement?
The prescribing physician or other prescriber. The exception rule turns on that statement, and the plan may accept it orally before asking for it in writing. A request filed without one has started a clock the plan is allowed to run out.
Does this page tell me whether my own request will be approved?
No. Covered Weight publishes what a named, dated, published rule says and nothing about how any particular request will be decided. The notice you receive from your plan is the document that governs your case, including the address a request has to reach and the date it has to reach it by.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 7, 2026
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Such term does not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title
Excerpt ends before the sentence continues with the carve-backs for smoking cessation agents and barbiturates. The en dash inside the cross-reference is the character the source prints. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 7, 2026
Read the line this comes from
The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.
Two consecutive paragraphs joined by a single space: the (d)(2) lead-in and item (A). No characters were changed. Cited here for the Part D question rather than the Medicaid one, because the Part D definition adopts this list by cross-reference.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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The Part D plan sponsor must grant an exception whenever it determines that the drug is medically necessary, consistent with the physician's or other prescriber's statement
Trimmed at the 200-character budget before the sentence continues "under paragraph (b)(5) of this section, and that the drug would be covered but for the fact that it is an off-formulary drug". The trailing clause is the one that keeps this rule inside the covered-drug definition rather than around it.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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An enrollee, the enrollee's representative, or the prescribing physician or other prescriber (on behalf of the enrollee) may file a request for an exception.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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If a supporting statement is not received by the end of 14 calendar days from receipt of the exceptions request, the Part D plan sponsor must notify the enrollee
The third sentence of paragraph (b), trimmed at the 200-character budget before it repeats the outer-limit wording and the 72-hour figure. A separate key from part_d_coverage_determination_standard_42cfr423_568b because the two facts are different sentences doing different work, and one key must never carry two facts a reader could check separately.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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Appeal procedures that meet the requirements of this subpart for issues that involve coverage determinations.
Item (iv) reads on from the lead-in at (a)(1), "A Part D plan sponsor, for each Part D plan that it offers, must establish and maintain".
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its determination as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receipt of the request
Mid-sentence excerpt of the first sentence of paragraph (b), which opens "When a party makes a request for a drug benefit, the Part D plan sponsor must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate)". Trimmed only to stay inside the 200-character budget; no characters were changed.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its decision, whether adverse or favorable, as expeditiously as the enrollee's health condition requires, but no later than 24 hours after receiving the request
Mid-sentence excerpt of the first sentence of paragraph (a), which opens "Except as provided in paragraph (b) of this section, a Part D plan sponsor that approves a request for expedited determination must make its determination and notify the enrollee".
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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a request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice
Excerpt of the first sentence of paragraph (b), which opens "Except as provided in paragraph (c) of this section" and continues past the budget with the at-risk determination cross-reference. Paragraph (c) is the good-cause extension the record's note names.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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of its redetermination as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days from the date it receives the request for a standard redetermination
Mid-sentence excerpt of item (a)(2), which opens "If the Part D plan sponsor makes a redetermination that affirms, in whole or in part, its adverse coverage determination or at-risk determination, it must notify the enrollee in writing". Paragraph (b) sets a different window for a request to be paid back for a drug already bought, which is why the record's note names the distinction.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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notice of its decision as expeditiously as the enrollee's health condition requires but no later than 72 hours after receiving the request
Mid-sentence excerpt of item (d)(1), which opens "A Part D plan sponsor that approves a request for expedited redetermination must complete its redetermination and give the enrollee (and the prescribing physician or other prescriber involved, as appropriate),".
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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must file a written request for reconsideration with the IRE within 60 calendar days after receipt of the written redetermination by the Part D plan sponsor
Excerpt of the third sentence of paragraph (a), whose subject is "The enrollee, or the enrollee's prescribing physician or other prescriber (acting on behalf of the enrollee)". Paragraph (c) adds the condition the record's note names for a drug that is not on the formulary.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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the reconsideration must be made by a physician with expertise in the field of medicine that is appropriate for the services at issue
Mid-sentence excerpt of paragraph (e), which opens "When the issue is the denial of coverage based on a lack of medical necessity (or any substantively equivalent term used to describe the concept of medical necessity)" and closes with the sentence that the physician need not be of the same specialty as the prescriber.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-08-05 · Read Aug 7, 2026
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must not exceed the deadlines applicable in § 423.590, including those deadlines that are applicable when a request for an expedited reconsideration is received and granted.
The close of paragraph (d), whose sentence opens "The independent review entity must conduct the reconsideration as expeditiously as the enrollee's health condition requires but". The section number sign is the character the source prints. This is a cross-reference rather than a figure, which is why the two durations it backs carry 423.590's numbers and cite 423.600(d) as the rule that imports them.
