Medicare to cover GLP‑1s
Medicare Part D will allow beneficiaries to access GLP‑1 weight‑loss medications for as little as $50/month starting July 1, 2026, as a bridge to the broader CMS “BALANCE” Model launching in 2027 WISH‑TV. The change aims to expand access for millions of older Americans who previously faced high out‑of‑pocket costs for prescription obesity therapies WISH‑TV.
The Medicare GLP‑1 Bridge is a time‑limited demonstration that will operate through Dec. 31, 2026 and run outside the usual Part D benefit and payment flow, with CMS using a single central processor for prior authorization and payments. (cms.gov) Participation requires enrollment in a Medicare Part D plan and clinical eligibility tied to BMI — at least 35 alone or 27 with specified comorbidities — as laid out in CMS guidance. (kff.org) CMS and program documents identify specific weight‑loss GLP‑1 products to be included at launch, naming Wegovy (semaglutide) and Zepbound (tirzepatide) among the therapies covered under the bridge demonstration. (kff.org) Claims processed under the bridge program are explicitly excluded from Part D deductibles and from the Part D annual out‑of‑pocket cap, and beneficiaries who receive Low‑Income Subsidy help through Part D cannot use those subsidies for bridge fills. (kff.org) The longer‑term BALANCE Model remains voluntary: CMS said it expects Medicaid participation as early as May 2026, a Medicare Part D start in January 2027, and it issued a Request for Applications to manufacturers and notices of intent to plans with deadlines tied to Jan. 8, 2026. (cms.gov) Estimates suggest millions of Medicare enrollees could meet broad overweight or obesity diagnoses, with a prior KFF analysis noting roughly 14 million beneficiaries had such diagnoses in 2020, though CMS cautions that the bridge’s specific clinical criteria will reduce the eligible pool. (kff.org)
