Medicare and Ozempic/Wegovy

Medicare is not broadly covering Ozempic or Wegovy for weight loss through ordinary Part D plans in 2026. Instead, the Centers for Medicare & Medicaid Services is launching a separate “Medicare GLP-1 Bridge” on July 1, 2026, for eligible beneficiaries. (cms.gov) CMS says the bridge program will run from July 1, 2026, through December 31, 2027, outside the normal Medicare Part D coverage and payment system. Part D sponsors do not have to opt in, and CMS will use a central processor for prior authorization, claims, and pharmacy payment. (cms.gov) The agency announced the bridge and the broader BALANCE model on December 23, 2025. CMS said BALANCE is a voluntary test meant to let Medicare Part D plans and state Medicaid programs cover certain glucagon-like peptide-1, or GLP-1, drugs for weight management while CMS negotiates pricing and coverage terms. (cms.gov) That is a narrower change than the claim that “Medicare now covers” these drugs for weight loss across the program. CMS still says Medicare and Medicaid generally do not cover GLP-1 drugs for the weight-loss indication today, and the bridge is being used as a temporary path before the Medicare side of BALANCE starts in 2027. (cms.gov) The old rule has been straightforward for years: Medicare Part D excludes drugs “when used for anorexia, weight loss or gain,” even for morbid obesity. CMS repeated that policy in its excluded-drug guidance, which is why coverage has usually depended on another Food and Drug Administration-approved use, not weight loss by itself. (cms.gov) That exception already mattered for Wegovy after the Food and Drug Administration expanded its label on March 8, 2024. The agency approved Wegovy to reduce the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and obesity or overweight, based on a trial of more than 17,600 participants. (fda.gov) CMS under the Biden administration had proposed a broader reinterpretation in November 2024 that would have allowed Part D coverage of anti-obesity drugs for obesity treatment. An HHS analysis said that proposal could have opened access to about 3.4 million Medicare beneficiaries with obesity and cut out-of-pocket costs by as much as 95% for some enrollees. (aspe.hhs.gov) But CMS’s April 4, 2025 final rule did not finalize that reinterpretation. The agency’s current 2026 approach is the bridge demonstration plus the BALANCE model, not a blanket Part D benefit change for weight-loss prescribing. (cms.gov) CMS has not posted public, plan-by-plan beneficiary price tables for the bridge on the pages it has released so far. The agency says it will provide additional design information in spring 2026, while BALANCE materials say Medicare Part D participation in that model begins January 1, 2027. (cms.gov 1) (cms.gov 2) So the cleanest way to read the 2026 update is this: Medicare is opening a temporary, CMS-run access route for some GLP-1 weight-management drugs, but it has not converted standard Medicare Part D into universal coverage for Ozempic or Wegovy prescribed solely for weight loss. (cms.gov)