For years, many Medicare beneficiaries have been interested in weight management medications like Ozempic or Wegovy, but Medicare’s coverage restrictions have limited access. That’s beginning to change.
The Centers for Medicare & Medicaid Services (CMS) recently announced the BALANCE Model, a new weightloss pilot program designed to make GLP-1 weight management drugs (like Ozempic and Wegovy) more accessible to eligible Medicare and Medicaid beneficiaries.
This guide explains what this weight loss pilot program covers, who may qualify, and when you could potentially get access to join the program..
Why Haven’t Weight Loss Drugs Been Covered by Medicare?
When Congress created Medicare Part D in 2003, the law excluded coverage for drugs used for weight loss, weight gain, or cosmetic purposes. At that time, weight-loss drugs weren’t as effective as they are today, and obesity wasn’t yet widely recognized as a chronic disease requiring medical treatment.
This meant that even if a Part D plan wanted to cover a weight loss drug, it couldn’t legally offer it.
That’s why medications like Ozempic are currently only covered by Medicare Part D when prescribed for diabetes—not for weight management. And Wegovy, which has FDA approval for “chronic weight management,” hasn’t been covered under Part D.
What Has Changed?
Medicine has grown a lot since 2003. Nowadays, medications like Ozempic and Wegovy have been shown in clinical trials to help people consistently lose weight, which we used to only typically see with bariatric surgery.
Research now recognizes that being overweight or obese can lead to type 2 diabetes, cardiovascular disease, and sleep apnea. According to CMS, over 70% of adults in the United States are classified as obese/overweight.
CMS created the “BALANCE Model” weightloss pilot program to test whether these medications can improve long-term health outcomes if they were more accessible.
What Is the BALANCE Model Weight Loss Pilot Program?
BALANCE stands for Better Approaches to Lifestyle and Nutrition for Comprehensive Health.
The BALANCE Model is a voluntary weightloss pilot program where CMS works directly with drug manufacturers on behalf of Medicare Part D plans and state Medicaid agencies.
They’re negotiating drug pricing, coverage terms, and who qualifies—all with the goal of making these medications more affordable for patients and taxpayers.
Here’s what you need to know about this weight-loss pilot program:
- The program is voluntary—Part D plans, states, and drug manufacturers can choose whether to join. This means your eligibility will depend on which manufacturers, states, and plans decide to participate.
- CMS is negotiating pricing directly with manufacturers, including Eli Lilly and Novo Nordisk.
- If you qualify, you’ll also get access to lifestyle support programs alongside your medication.
- The program is set to run through December 2031.
What Medications May Be Covered?
The BALANCE Model weight loss pilot program focuses on GLP-1 medications that have FDA approval for weight management. These include:
- Semaglutide (brand names: Wegovy, Ozempic, Rybelsus)
- Tirzepatide (brand names: Zepbound, Mounjaro)
- Liraglutide (Saxenda)
So how do these drugs work? They mimic natural hormones your body produces in your digestive system. They help reduce your appetite, slow down digestion, and help you feel full longer—which can lead to weight loss when combined with diet and exercise.
Timeline: When Could You Get Access?
Here’s what CMS has announced about when the weight loss pilot program will roll out:
July 2026 — Medicare Bridge Program
Before the full BALANCE Model launches, CMS plans to roll out a short-term program for Medicare beneficiaries. If manufacturers choose to participate, eligible Part D enrollees could start accessing GLP-1 medications through this bridge program.
Under this program, eligible Medicare beneficiaries would pay just $50 per month for GLP-1 medications. This runs outside the normal Part D system, so Part D plans won’t carry the financial risk during this phase.
January 2027 — Full BALANCE Model for Medicare Part D
The complete weight loss pilot program is set to launch for Medicare Part D plans in January 2027. Your actual coverage will depend on which plans and manufacturers choose to participate.
May 2026 — Medicaid
State Medicaid agencies can start joining the BALANCE Model as early as May 2026, with coverage rolling out state by state. According to KFF, only about 13 states covered GLP-1s for weight loss as of 2024.
Who May Be Eligible for the Weight Loss Pilot Program?
CMS is still working out the exact eligibility requirements through negotiations with manufacturers. Based on what’s been announced so far, you may be eligible if you:
- Have a BMI of 35 or higher
- Have a BMI over 30 along with heart failure, uncontrolled high blood pressure, or chronic kidney disease
- Have a BMI of 27 or higher, along with prediabetes or a history of heart disease
You’d also need to participate in a lifestyle support program that covers healthy eating and physical activity—this lines up with FDA recommendations to use these medications alongside lifestyle changes.
According to senior administration officials, roughly 10% of Medicare beneficiaries would qualify under the expanded coverage.
Keep in mind: This weight loss pilot program won’t guarantee coverage for everyone. Whether you can actually get access will depend on manufacturer participation, plan participation, and whether you meet the eligibility requirements.
What Will It Cost?
One big goal of the BALANCE Model weight loss pilot program is to bring down out-of-pocket costs.
During the July 2026 bridge program: If you’re eligible and manufacturers participate, you’d pay $50 per month for GLP-1 medications.
Under the full BALANCE Model: CMS is negotiating set pricing and out-of-pocket limits with manufacturers. The negotiated price is around $245 per month for injectables—way lower than list prices that can top $1,000 a month.
To put that in perspective, without insurance coverage, these medications can run you $13,000-$14,000 per year out of pocket.
If oral (pill form) GLP-1 medications get FDA approval, starting doses are expected to cost around $149-$150 per month.
You May Also Get Lifestyle Support
The BALANCE Model pairs medication access with lifestyle support. CMS knows that weight management medications work best when combined with healthy eating and physical activity.
If you get GLP-1s through the weight loss pilot program, you’ll have access to a lifestyle support program provided by the manufacturer at no extra cost. These programs typically include:
- Tips for keeping the weight off
- Guidance on healthy eating and lower-calorie diets
- Physical activity recommendations
- Support for building lasting healthy habits
What Can You Do Right Now?
The weight loss pilot program won’t be available until mid 2026 into 2027, but here’s what you can do in the meantime:
Talk to your doctor: If you’re concerned about weight management, your doctor can help you figure out whether GLP-1 medications might be right for you.
Watch for plan announcements: During Annual Enrollment Period (October 15 through December 7), keep an eye on which Medicare Part D plans and Medicare Advantage plans announce they’re joining the BALANCE Model for 2027.
Check your current coverage: Medicare Part D already covers some GLP-1 medications when prescribed for diabetes or heart disease. If you have one of these conditions, you might already have access through your current plan.
Stay informed: CMS will release more details about the weight loss pilot program in early 2026, including final eligibility requirements and which plans are participating.
Have Questions About Medicare?
If you’d like help understanding your Medicare options or want to learn more as details come out about the BALANCE Model weight loss pilot program, our licensed insurance agents are happy to help.
PlanFit is a licensed insurance agency. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.