Millions of Americans on Medicare and Medicaid may soon get access to popular weight loss medications like Ozempic, Wegovy, Mounjaro, and Zepbound under a new federal program.
The Centers for Medicare & Medicaid Services (CMS) announced the BALANCE Model on December 23, 2025. It’s designed to make expensive GLP-1 drugs more affordable while helping people lose weight and improve their health.
Right now, Medicare is not allowed to cover drugs used only for weight loss. But this program changes that.
“This initiative reflects efforts to democratize access to these breakthrough drugs,” according to the official CMS announcement at cms.gov.
What the BALANCE Model Does
The program works by letting CMS negotiate lower prices directly with drug makers like Eli Lilly and Novo Nordisk. It also sets standard rules for who qualifies and how much patients will pay.
Here’s what’s included:
- Lower out-of-pocket costs for Medicare Part D and Medicaid members
- Free lifestyle support programs like nutrition counseling and fitness coaching
- Uniform coverage rules across participating states and plans
- No deductibles for some beneficiaries under a temporary bridge program
The program is voluntary, meaning not every state or insurance plan will join right away.
Who Can Get Coverage?
To qualify, patients typically need to:
- Be enrolled in Medicare Part D or Medicaid
- Live in a participating state or have a participating plan
- Meet medical criteria, such as a BMI showing obesity
- Get prior authorization from their doctor
People already using GLP-1 drugs for diabetes may also qualify for lower prices if their plan participates.
When Does It Start?
The rollout happens in phases:
- January 8, 2026: Deadline for manufacturers and states to apply
- May–December 2026: States begin joining Medicaid program
- July 2026: Temporary Medicare bridge program starts with $50/month cost-sharing
- January 2027: Full Medicare Part D program launches
The bridge program is meant to give earlier access to Medicare members before the full model begins.
Why This Matters
GLP-1 medications have been shown to help people lose an average of 10% or more of their body weight. They also reduce the risk of serious health problems like diabetes, heart disease, and stroke.
But the drugs are expensive — often over $1,000 per month without insurance.
According to the U.S. Food and Drug Administration (FDA), these medications work best when combined with reduced-calorie diets and increased physical activity, which is why the BALANCE Model includes free lifestyle coaching.
What to Do Next
If you’re on Medicare or Medicaid and interested in these drugs:
- Talk to your doctor about whether you qualify
- Contact your insurance plan or state Medicaid office to see if they’re participating
- Check the official CMS page for updates: cms.gov/priorities/innovation/innovation-models/balance
Coverage is not automatic. It depends on where you live and whether your plan or state signs up.
The program will run through December 2031, with CMS tracking results to see how well it works.
This could be one of the biggest expansions of weight loss drug coverage in U.S. history — but only if enough states and plans participate.
