This month's author is, Cristy Gallagher, the Associate Director of Research and Policy at the STOP Obesity Alliance.
Last fall, the Trump administration announced an historic expansion of obesity treatment coverage for Medicare and Medicaid beneficiaries. The announcement from the White House was part of the “most-favored-nation” agreement that the Administration made with drug manufacturers Novo Nordisk and Eli Lilly. It came with the news that the Centers for Medicare and Medicaid (CMS) plan to implement two demonstration programs that provide coverage of GLP-1 obesity medications: the Medicare GLP-1 Bridge and the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) models.
This will be the first time that Medicare will be able to cover Food & Drug Administration (FDA)-approved for beneficiaries. Medicare has been prohibited from covering medications for weight loss or weight gain since the development of the Part D prescription drug program. CMS has historically interpreted the Medicare prohibition to mean that Part D plans could not cover obesity medications, creating a significant gap in care for older Americans with obesity.
The Treat and Reduce Obesity Act (TROA), which has been introduced in Congress, would fix this prohibition by allowing Medicare Part D to cover FDA-approved obesity medications. In 2024, the Biden administration proposed a rulethat would have aligned coverage policy to reflect the prevailing medical consensus that obesity is a chronic disease, thereby rendering treatment of obesity as a medically necessary service under Medicare. However, in 2025, the Trump administration did not finalize this policy through the rulemaking process, fearing that the federal government did not have the authority to make the change without Congressional approval.
GLP-1 Bridge for Medicare Beneficiaries
CMS announced that they will administer the Medicare GLP-1 Bridge using Section 402 authority, which will allow them to provide a short-term program where Medicare beneficiaries can receive FDA-approved GLP-1 obesity medications. The GLP-1 Bridge program, which will start on July 1, 2026, will operate outside the Medicare Part D payment system.
CMS announced on April 21st that they would extend the timeline for the temporary GLP-1 Bridge model through the end of December 2027, providing 18 months of coverage. The extension of the Bridge program will provide CMS the opportunity to collect additional data based on who signs up for coverage and what that coverage will cost. The extension will also help facilitate a smoother transition for beneficiaries from Bridge to the BALANCE program.
We are expecting additional details for how beneficiaries can sign up for the GLP-1 Bridge program soon, but here is what we know so far:
- Medicare beneficiaries must be enrolled in a Medicare Part D plan or a Medicare Advantage plan with prescription drug coverage.
- A provider must submit a prescription and prior authorization request to a CMS central processor confirming eligibility.
- Beneficiaries must meet specific clinical eligibility criteria.
- GLP-1 medications, including Wegovy, Zepbound, and Foundayo, will be covered.
- GLP-1 medications already covered under other indications (diabetes, obesity w/ sleep apnea, and MASH) will stay covered under Part D plans.
- Manufacturers will provide medications at a net price of $245 for a monthly supply, and beneficiaries will pay a $50 copay for each prescription filled. Pharmacies will collect the beneficiary copay and submit claims through the CMS central processor for reimbursement.
CMMI BALANCE Demonstration Program: Medicare
CMS’ Center on Medicare and Medicaid Innovation (CMMI) will be responsible for administering the BALANCE demonstration model using the 1115A authority. The BALANCE model includes coverage for both Medicare and Medicaid. BALANCE is a voluntary model for manufacturers, Part D insurance plan sponsors, beneficiaries, and State Medicaid plans. The model will run for 5 years, concluding in December 2031.
The applications sent from CMMI to the Part D plans were due on April 20th. CMMI required that enough Part D plans sign up to reach a threshold of 80% of the beneficiaries to be covered for the model to move forward. However, CMS announced on April 21st that they would delay the implementation of the model until at least 2028, perhaps because too few Medicare Part D plans had signed up to participate. The delay will provide additional time to gather data to inform the potential implementation of BALANCE for Medicare in 2028.
CMMI BALANCE Demonstration Program: Medicaid
In the meantime, the BALANCE demonstration program for state Medicaid programs will continue. CMMI will accept applications from State Medicaid agencies through July 31, 2026. States may choose to start participating in BALANCE starting on a date of their choosing between May 1, 2026, and January 1, 2027. States that do not join the model by January 1, 2027, will only be allowed to participate in the model at the discretion of CMS. It is not yet clear which states plan to join the BALANCE model.
Clinical Criteria for Bridge and BALANCE
The clinical criteria to participate in the Bridge and BALANCE models are similar (see chart from KFF below). Under Bridge, however, GLP-1 medications already covered under other indications (diabetes, obesity w/ sleep apnea, and MASH) will stay covered under Part D plans. The BALANCE model will also require that the medication be paired with access to lifestyle support provided by the manufacturers.
For too long, healthcare systems have waited to treat the consequences of obesity rather than addressing the disease itself. We now have a pathway to coverage for the newest obesity medications under these two models. Older Americans have been waiting for access to the same standard of care that is increasingly available in commercial plans, and for the first time a pathway has opened to provide that access. The next step will be to publicize this opportunity to people with obesity and the providers that care for them.