CMS announced the voluntary BALANCE demonstration to expand Medicare access to GLP-1 weight-loss drugs after negotiated discounts with Eli Lilly and Novo Nordisk. Eligible beneficiaries could pay $50 per month, with CMS negotiating the remaining drug costs; officials estimate about 10% of Medicare enrollees may qualify. Participation by manufacturers, states and Part D plans is voluntary, with a short-term demonstration possibly starting by July and running through December 2031 while broader state and plan participation could begin in 2026–2027.
Medicare Signals Path To Cover GLP-1 Weight-Loss Drugs Through Voluntary BALANCE Model — $50/Month For Eligible Beneficiaries
Certain Medicare beneficiaries could have increased access to Wegovy for weight loss next year. - Shelby Knowles/Bloomberg/Getty Images
The Centers for Medicare & Medicaid Services (CMS) announced a voluntary demonstration called Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) that could let some Medicare beneficiaries access highly popular GLP-1 weight-loss drugs for $50 per month after negotiated discounts with manufacturers.
By law, Medicare generally cannot cover medications prescribed solely for weight loss. Both the prior and current administrations have argued that GLP-1 therapies — which are used for diabetes and have shown substantial weight-loss effects — play an important role in treating chronic conditions and improving population health.
What CMS Is Proposing
Under the BALANCE model, CMS will negotiate discounted prices with manufacturers (including Eli Lilly and Novo Nordisk) to expand access to GLP-1 drugs in Medicare Part D plans while pairing drug treatment with lifestyle supports. Participation will be voluntary for drugmakers, states and Part D plans. CMS also plans to negotiate discounted pricing for state Medicaid programs.
"The effort seeks to democratize access to weight-loss medication, which has been out of reach for so many in need," CMS Administrator Dr. Mehmet Oz said, adding that the initiative "pairs breakthrough science with healthy living to cut costs while empowering Americans to take control of their health."
Timeline
CMS said a separate short-term demonstration could allow some Medicare beneficiaries to access GLP-1 drugs as soon as July; that demonstration is slated to run through December 2031. States may opt into the Medicaid portion beginning May 2026, and Medicare Part D plans may join starting January 2027. Exact start dates and coverage details will depend on negotiations and voluntary participation.
Who Would Be Eligible
The announced agreement would make expanded access available to beneficiaries who meet clinical criteria, such as people who are overweight with prediabetes or a history of stroke or other cardiovascular disease, and people with obesity who also have diabetes or uncontrolled high blood pressure. Senior officials estimate roughly 10% of Medicare enrollees could qualify under the terms described by the administration.
Costs And Structure
Under the announced arrangement, eligible beneficiaries would pay $50 per month, while Medicare would cover the remaining negotiated portion (the administration cited a Medicare contribution of about $245 for covered drugs in its statement). CMS and the drugmakers say negotiated price reductions are intended to make the expansion cost-neutral to Medicare. By contrast, a prior Biden administration proposal to reinterpret coverage rules for obesity treatment — without the same negotiated price cuts — had been estimated to add roughly $25 billion to Medicare spending over 10 years.
State Coverage And Manufacturer Commitments
Eli Lilly and Novo Nordisk have agreed to provide lower prices to state Medicaid programs, though implementation timing will vary by state and depend on separate negotiations. As of Oct. 1, sixteen state Medicaid programs reported covering GLP-1s for obesity, according to KFF; other states have scaled back or restricted coverage because of costs.
Concerns, Effectiveness And Next Steps
Advocates and insurers have welcomed the move in principle but asked for details on eligibility, insurer costs and long-term outcomes. The Alliance of Community Health Plans noted evidence that GLP-1 medications can improve health outcomes but warned that side effects lead some patients to discontinue therapy within the first year. Implementation will require coordination between federal agencies, states, Part D plans and manufacturers, and final participation and pricing will determine the program's reach and fiscal impact.
"ACHP looks forward to working with the Administration on weight loss therapies that deliver the right treatment, at the right time, at an affordable price," the Alliance said.
CMS highlighted the potential public-health impact: more than 70% of U.S. adults are classified as having overweight or obesity — conditions that raise the risk for multiple chronic diseases.
