Medicare plan for GLP‑1s faces insurer pushback

The Trump administration’s Medicare plan for weight-loss drugs hit resistance this week when major insurers declined to fully sign on for 2027. (modernhealthcare.com) The program, called BALANCE, was announced by the Centers for Medicare & Medicaid Services on December 23, 2025 as a voluntary model for Medicare Part D plans and state Medicaid agencies. CMS said Medicare Part D participation would begin in January 2027, with the agency negotiating lower net prices and standardized coverage terms for GLP-1 drugs. (cms.gov) GLP-1 drugs are a class of medicines used for diabetes, obesity, cardiovascular disease and other conditions; in Medicare, they are generally covered now only when prescribed for an approved use other than obesity. KFF said federal law has long barred Medicare from covering drugs when they are used specifically for weight loss. (kff.org) That legal gap is why CMS built BALANCE as a demonstration program instead of a standard Part D benefit. The model was supposed to test whether Medicare could expand access to obesity drugs while pairing them with lifestyle support and cost controls. (cms.gov, kff.org) The problem is participation. CMS could move forward with the Medicare portion only if Part D sponsors representing 80% of Part D enrollment applied by April 20, 2026, and Becker’s reported on April 21 that the agency was pausing the Medicare model after failing to reach that threshold. (beckershospitalreview.com) UnitedHealth said it wanted to “find a path to yes,” but Bobby Hunter, the insurer’s chief of government programs, said there were “notable challenges and outstanding questions” in the current structure. Bloomberg and Reuters also reported that CVS Health, whose insurance arm is Aetna, declined to participate. (money.usnews.com, stocktwits.com) CMS did not abandon coverage altogether. Modern Healthcare, citing Bloomberg, reported that the federal government will pay for obesity-drug coverage in Medicare through the end of 2027 instead of making insurers absorb the cost next January. (modernhealthcare.com) A separate short-term program, the Medicare GLP-1 Bridge, is still set to start in July 2026. CMS says that bridge demonstration was designed to carry beneficiaries into the longer BALANCE model in Medicare Part D. (cms.gov) Drugmakers felt the uncertainty immediately. Reuters reported Eli Lilly shares fell nearly 2% and U.S.-listed Novo Nordisk shares dropped 3.4% on April 21 as investors reassessed how much Medicare-backed demand the companies could count on. (money.usnews.com) For now, Medicare beneficiaries may still see lower-cost access beginning July 1, 2026, but the administration’s original idea of broad insurer-backed coverage in 2027 looks weaker than it did four months ago. (cms.gov, beckershospitalreview.com)