GLP-1 Obesity Drug News Today: Medicare Update—What It Means for You

Medicare News: What’s Changing for Medicare and GLP-1 Drugs?

Federal law has long prohibited Medicare Part D from covering drugs prescribed solely for weight loss—even as demand for medications, such as Wegovy® and Zepbound®, has surged. In fact, Wegovy® was approved by the FDA for chronic weight management in June 2021. In December 2025, the FDA also approved an oral Wegovy® pill for weight management.

But weight loss drugs covered by insurance tend to walk a fine line. The good news? Things are changing.

In late 2025, the federal government announced new pricing and access initiatives involving GLP-1 manufacturers Eli Lilly and Novo Nordisk, aimed at improving affordability for Medicare and Medicaid beneficiaries while controlling long-term program costs. 

Then, on December 23, 2025, the Centers for Medicare & Medicaid Services (CMS) unveiled the BALANCE Model—a voluntary program designed to expand access to GLP-1 drugs for weight management (subject to negotiated coverage/access criteria and voluntary participation by manufacturers, states, and Part D plans).

Here’s what this means in more practical terms:

As early as July 2026, CMS plans to test a voluntary Medicare GLP-1 payment demonstration that operates outside the Medicare Part D benefit’s usual coverage and payment flow. Under this model, beneficiary cost-sharing is expected to be significantly lower than current retail prices, with CMS stating eligible Medicare beneficiaries will pay $50 a month for GLP-1 medications under the demonstration (subject to negotiated access criteria and participation).  

The full BALANCE Model is scheduled to begin in January 2027 and run through December 2031, pending participation by Medicare Part D plans, drug manufacturers, and, on the Medicaid side, state agencies. However, participation is voluntary, meaning coverage details and availability may vary by plan and location. 

Manufacturers interested in participating have until January 8, 2026, to respond to CMS’s BALANCE Request for Applications (RFA), and CMS has said additional participation information will be released in early 2026—so beneficiaries may be able to factor participation into their plan decisions during the next open enrollment period (October 15-December 7, 2026).

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Who Will Qualify for Coverage?

CMS has not yet released final eligibility criteria for the GLP-1 demonstration or the BALANCE model. However, early reporting suggests eligibility may focus on beneficiaries with obesity who also have other FDA-approved medical indications, such as cardiovascular disease, metabolic risk factors, or other obesity-related illnesses.

Reported eligibility frameworks have referenced combinations such as:

• Overweight or obesity alongside prediabetes or cardiovascular disease
• Obesity combined with conditions like heart failure, hypertension, or chronic kidney disease

Ultimately, however, final eligibility rules, prior authorization requirements, and clinical thresholds will be determined by participating Medicare Part D plans and CMS guidance closer to launch.

While CMS has not yet published an official list of covered medications, GLP-1 drugs commonly prescribed for diabetes, cardiovascular risk reduction, sleep apnea, and other obesity-related conditions may be considered, subject to CMS guidance and voluntary participation by manufacturers and plans. 

It’s worth noting that this doesn’t change the fact that Medicare still generally does not cover GLP-1 drugs prescribed solely for weight loss under current law outside of specific demonstration/model pathways. Coverage under BALANCE would follow negotiated access criteria and participation rules.

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What Does Medicare Currently Cover?

Right now, Medicare Part D plans can cover certain GLP-1 drugs, but only for specific FDA-approved uses beyond weight loss, such as:

• Ozempic®: Covered for Type 2 diabetes (and, in adults with type 2 diabetes and chronic kidney disease, to reduce the risk of kidney disease worsening/kidney failure and related outcomes).
• Wegovy®: May be covered to reduce cardiovascular risk in adults with heart disease who are overweight or obese, and for the liver condition MASH.
• Zepbound®: May be covered for moderate-to-severe obstructive sleep apnea in adults with obesity.
• Mounjaro®: Covered for Type 2 diabetes.

At the same time, coverage still depends on your specific plan and whether you meet your plan’s criteria. 

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What About Medicaid?

Ultimately, Medicaid coverage for GLP-1 weight loss drugs is a state-by-state decision. 

As of late 2025, 16 state Medicaid programs reported covering GLP-1s for obesity treatment. But budget pressures are pushing some states in the opposite direction.

States that have recently cut or restricted GLP-1 coverage for weight loss include:

• North Carolina (ended coverage October 2025)
• California, New Hampshire, and South Carolina (ending coverage January 2026)
• Pennsylvania (restricting coverage to non-weight-loss indications)
• Michigan (limiting to “morbidly obese” patients only)

The BALANCE model will open to state Medicaid agencies as early as May 2026, which could eventually bring more uniform pricing and access. But timing will vary depending on whether individual states choose to participate—and whether they can secure the funding to do so.

For now, if you’re on Medicaid and wondering, Does Medicaid cover weight loss drugs, the answer depends entirely on where you live. Checking your state’s Medicaid website or your specific plan can confirm what coverage is available to you.

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What Can You Do Now?

If you’re on Medicare or Medicaid and interested in GLP-1 treatment, here’s how to stay ahead of the changes:

1. Check your current plan’s formulary to see whether any GLP-1 drugs are covered for your conditions (diabetes, cardiovascular disease, sleep apnea, etc.).
2. Talk to your healthcare provider about whether you might qualify under the new eligibility criteria once the program launches.
3. Watch for plan updates during the 2026 open enrollment period; plans may indicate whether they’re participating in BALANCE, and details may vary by plan.

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Final Thoughts

The Medicare landscape for GLP-1 drugs is changing. While $50-per-month access isn’t here yet, this framework may eventually create new pathways to access, depending on individual eligibility, plan participation, and timing.

As always, talk to a licensed healthcare provider to determine whether GLP-1 treatment is appropriate for you. Coverage, eligibility, and timing will depend on your individual health situation and your individual plan.

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