Does Medicare Cover Weight Loss Drugs? GLP-1s, Ozempic, and the BALANCE Program in 2026

Weight loss drugs like Ozempic, Wegovy, and Zepbound have dominated headlines for the past several years. These GLP-1 receptor agonist medications have shown remarkable effectiveness for weight management and related health conditions, but their high cost has put them out of reach for many Americans — especially Medicare beneficiaries, who have historically been excluded from coverage for anti-obesity drugs.

That is changing in 2026. The Centers for Medicare and Medicaid Services (CMS) has announced the BALANCE Model — a groundbreaking pilot program that will provide Medicare coverage for FDA-approved anti-obesity medications starting in July 2026. For the first time, millions of Medicare beneficiaries could gain access to GLP-1 drugs for weight loss at an affordable copay.

This guide covers everything you need to know about Medicare and weight loss drugs in 2026: what is currently covered under Medicare Part D, how the BALANCE program works, who qualifies, what you will pay, and how this fits into the broader Medicare system.

Why Medicare Has Not Covered Weight Loss Drugs — Until Now

Since the Medicare Modernization Act of 2003 established the Part D prescription drug benefit, federal law has explicitly excluded coverage for drugs used for "anorexia, weight loss, or weight gain." This statutory exclusion has meant that even as effective new anti-obesity medications came to market, Medicare Part D plans could not cover them when prescribed specifically for weight management.

This exclusion has persisted despite growing evidence that obesity is a chronic disease affecting more than 40 percent of American adults and contributing to a wide range of serious health conditions, including heart disease, type 2 diabetes, certain cancers, and joint problems. For Medicare beneficiaries — who tend to be older and more vulnerable to obesity-related complications — the lack of drug coverage has been a significant gap in care.

Congress has considered legislation like the Treat and Reduce Obesity Act multiple times to remove this exclusion, but none of those bills have become law. Instead, CMS is using its authority through the CMS Innovation Center to test coverage through the BALANCE Model pilot program.

What Medicare Currently Covers for Weight Loss

While anti-obesity drugs have been excluded, Medicare does cover some weight-related services. Understanding what is already available can help you take advantage of benefits you may not know about.

Intensive Behavioral Therapy (IBT) for Obesity

Medicare Part B covers intensive behavioral therapy for obesity if you have a BMI of 30 or greater. This benefit includes:

• One face-to-face counseling session per week for the first month
• One session every two weeks for months two through six
• One session per month for months seven through twelve, if you meet the weight loss goal of at least 6.6 pounds during the first six months

These counseling sessions must be provided by a primary care physician or other qualified primary care provider in a primary care setting. There is no cost to you when the provider accepts Medicare assignment.

GLP-1 Drugs Covered for Diabetes Under Part D

This is an important distinction: Medicare Part D does cover GLP-1 medications when they are prescribed for type 2 diabetes. Ozempic (semaglutide), Mounjaro (tirzepatide), Trulicity (dulaglutide), and other GLP-1 receptor agonists approved for diabetes management are Part D covered drugs. Your cost-sharing will depend on which coverage phase you are in and where the drug falls on your plan's formulary tier.

However, the same active ingredients prescribed exclusively for weight loss — such as Wegovy (semaglutide at a higher dose approved for obesity) or Zepbound (tirzepatide approved for obesity) — have not been covered under standard Part D. The diagnosis code on your prescription matters: diabetes equals covered, obesity alone equals not covered.

Medicare Advantage Plans and Weight Loss

Some Medicare Advantage (Part C) plans have offered supplemental benefits related to weight management, such as gym memberships, nutrition counseling, or meal delivery programs. However, these supplemental benefits do not include coverage for anti-obesity prescription drugs. Medicare Advantage plans that include Part D drug coverage are subject to the same statutory exclusion as standalone Part D plans.

The BALANCE Model: Medicare's New Anti-Obesity Drug Pilot Program

The Broadening Access to Lifesaving Anti-Obesity and Nutrition Care Efficiently (BALANCE) Model is a CMS Innovation Center initiative announced in late 2025. It represents the most significant step toward Medicare coverage of weight loss medications in the program's history.

Here are the key details of the BALANCE Model:

• Launch date: July 1, 2026
• Duration: July 2026 through December 2030 (four and a half years)
• Estimated eligible population: Up to 3.4 million Medicare beneficiaries
• Maximum copay: $50 per month for covered anti-obesity medications
• Participation: Voluntary for Part D plan sponsors; beneficiaries must be enrolled in a participating plan
• Required components: Anti-obesity medication plus behavioral counseling

How the BALANCE Model Works

The BALANCE Model operates through the CMS Innovation Center's authority to test new payment and service delivery models. Rather than changing the law that excludes anti-obesity drugs from Part D, CMS is using its innovation authority to create a time-limited pilot that will measure whether covering these medications reduces total Medicare spending by preventing or improving obesity-related conditions.

Part D plan sponsors can voluntarily apply to participate in the model. Plans that are accepted will add FDA-approved anti-obesity medications to their formularies specifically for eligible beneficiaries. CMS will negotiate with drug manufacturers to secure rebates that offset the cost of covering these expensive medications.

The model takes a two-pronged approach:

1. Medication coverage: Participating plans will cover FDA-approved anti-obesity medications at a beneficiary copay of no more than $50 per month. This makes drugs that retail for $1,000 or more per month accessible to Medicare beneficiaries at a fraction of the cost.
2. Behavioral counseling: Participants must also engage in behavioral counseling that addresses nutrition, physical activity, and sustainable lifestyle changes. This requirement reflects clinical evidence that the best outcomes from anti-obesity medications occur when combined with lifestyle modification.

Who Is Eligible for the BALANCE Program?

To qualify for anti-obesity medication coverage through the BALANCE Model, you must meet all of the following criteria:

1. You must be enrolled in a Medicare Part D plan that participates in the BALANCE Model.
2. You must have a body mass index (BMI) of 30 or greater, which is the clinical threshold for obesity.
3. Alternatively, you may qualify with a BMI of 27 or greater if you also have at least one weight-related comorbidity, such as type 2 diabetes, hypertension, dyslipidemia (high cholesterol), obstructive sleep apnea, or cardiovascular disease.
4. Your physician must prescribe an FDA-approved anti-obesity medication and document that you meet the clinical eligibility requirements.
5. You must agree to participate in the behavioral counseling component of the program.

These eligibility criteria align with the FDA-approved indications for anti-obesity medications and with clinical guidelines from the American Medical Association, which recognized obesity as a disease in 2013.

Which Weight Loss Drugs Are Included?

The BALANCE Model covers FDA-approved anti-obesity medications. The GLP-1 receptor agonist drug class has been at the center of the anti-obesity medication revolution, and several key drugs are expected to be included.

Understanding GLP-1 Receptor Agonists

GLP-1 (glucagon-like peptide-1) receptor agonists are a class of medications that mimic a natural hormone produced in your gut. They work by slowing stomach emptying, reducing appetite, and helping regulate blood sugar. Originally developed for type 2 diabetes, clinical trials demonstrated that these drugs also produce significant weight loss — often 15 to 20 percent or more of body weight.

Here are the key medications in this drug class and how they relate to Medicare coverage:

Wegovy (semaglutide 2.4 mg): FDA-approved specifically for chronic weight management. This is the obesity-indication version of semaglutide and is expected to be a primary drug covered under the BALANCE Model. Wegovy has also received FDA approval for reducing cardiovascular risk in adults with obesity.

Zepbound (tirzepatide): FDA-approved for chronic weight management. Tirzepatide is a dual GIP/GLP-1 receptor agonist, meaning it targets two gut hormones rather than one. Clinical trials have shown weight loss averaging 20 percent or more of body weight. Zepbound is expected to be covered under the BALANCE Model.

Ozempic (semaglutide 0.5 mg, 1 mg, or 2 mg): FDA-approved for type 2 diabetes, not for weight loss. Ozempic is already covered under standard Medicare Part D when prescribed for diabetes. It contains the same active ingredient as Wegovy (semaglutide) but at a lower dose and with a different FDA indication. If your doctor prescribes Ozempic for diabetes, your Part D plan should cover it through the normal formulary process.

Mounjaro (tirzepatide): FDA-approved for type 2 diabetes. Like Ozempic, Mounjaro is the diabetes-indication version of tirzepatide and is already covered under standard Part D for diabetes treatment. It shares the same active ingredient as Zepbound.

Additional FDA-approved anti-obesity medications that may be included in the BALANCE Model formulary include older drugs such as Contrave (naltrexone-bupropion) and Qsymia (phentermine-topiramate), though the specific formulary will be determined by participating plans in coordination with CMS.

How Much Will You Pay? Costs Under the BALANCE Model

The cost savings under the BALANCE Model are substantial. To put the $50 maximum monthly copay in perspective, here is what these drugs typically cost and how the program changes the equation. For a broader look at all Medicare costs in 2026, see our detailed cost guide.

• Wegovy retail price: Approximately $1,300 per month without insurance
• Zepbound retail price: Approximately $1,060 per month without insurance
• BALANCE Model copay: No more than $50 per month
• Annual savings: Potentially $12,000 or more per year compared to paying out of pocket

CMS has also indicated that beneficiaries who qualify for the Low-Income Subsidy (Extra Help) program may pay less than the $50 monthly copay, though specific details on reduced cost-sharing for LIS beneficiaries are still being finalized.

It is important to note that anti-obesity medications covered under the BALANCE Model are treated separately from standard Part D drug spending. This means spending on these drugs will not count toward your Part D deductible or the $2,000 out-of-pocket cap established by the Inflation Reduction Act, but it also means you pay the flat copay rather than potentially higher cost-sharing under the standard Part D benefit structure.

How to Check if Your Plan Participates

Since the BALANCE Model is voluntary for Part D plan sponsors, not every Medicare drug plan will offer this coverage. Here is how to find out if your plan is participating:

1. Check Medicare.gov: CMS is expected to update the Medicare Plan Finder tool to indicate which plans participate in the BALANCE Model before the July 2026 launch date.
2. Contact your plan directly: Call the member services number on your Part D plan card and ask if your plan is participating in the CMS BALANCE Model for anti-obesity medication coverage.
3. Call 1-800-MEDICARE: You can call 1-800-633-4227 (TTY users: 1-877-486-2048), available 24 hours a day, 7 days a week, to ask about participating plans in your area.
4. Talk to your doctor: Your prescribing physician may have information about which plans in your area are participating, especially if they are already prescribing anti-obesity medications to other patients.
5. Work with a licensed insurance agent: A licensed Medicare insurance agent can help you compare plans and identify those participating in the BALANCE program.

What if Your Plan Does Not Participate?

If your current Part D plan does not join the BALANCE Model, you have several options to consider:

• Switch plans during the Annual Enrollment Period (October 15 through December 7) to a Part D plan that participates in the BALANCE Model for the following calendar year.
• Check whether a Special Enrollment Period (SEP) may be available specifically for beneficiaries who want to join a plan participating in the BALANCE Model. CMS may create a dedicated SEP for this purpose, though this has not been confirmed.
• If you have a Medicare Advantage plan with built-in Part D coverage, check whether your MA-PD plan sponsor is participating. If not, you would need to switch MA plans or move to Original Medicare with a standalone Part D plan that participates.
• Talk to your doctor about whether a GLP-1 drug prescribed for a covered condition (such as diabetes or cardiovascular risk reduction) might be an alternative pathway to coverage under standard Part D.

The Bigger Picture: Why CMS Is Testing This Model

CMS is not launching the BALANCE Model simply to provide a new drug benefit. The program is designed as a rigorous test of whether covering anti-obesity medications can actually save Medicare money in the long run by reducing the enormous costs associated with treating obesity-related diseases.

Consider the downstream costs of obesity in the Medicare population:

• Type 2 diabetes management costs Medicare an estimated $42 billion annually
• Cardiovascular disease treatment, much of which is obesity-related, is the single largest driver of Medicare spending
• Obesity increases the risk and cost of joint replacements, kidney disease, certain cancers, and hospitalizations
• Obese Medicare beneficiaries have healthcare costs roughly 40 percent higher than those at a healthy weight

If the BALANCE Model demonstrates that covering anti-obesity medications leads to meaningful reductions in these downstream costs, it could pave the way for permanent legislative changes to Medicare Part D's drug exclusion. This is why the pilot's success matters beyond the beneficiaries who directly participate — it could shape Medicare drug coverage policy for decades to come.

Steps to Take Now to Prepare for the BALANCE Program

Even though the BALANCE Model does not launch until July 2026, there are steps you can take now to prepare:

1. Talk to your doctor about whether an anti-obesity medication might be appropriate for you. Discuss your BMI, any weight-related conditions you have, and whether a GLP-1 or other anti-obesity drug could benefit your health. Having this conversation documented in your medical records can help when the program launches.
2. Review your current Part D plan. Understand which plan you are enrolled in and who the plan sponsor is. Larger plan sponsors may be more likely to participate in the BALANCE Model. Begin researching whether your plan sponsor has announced plans to join.
3. Take advantage of existing obesity benefits. If you have a BMI of 30 or higher, you can already access free intensive behavioral therapy for obesity through Medicare Part B. Starting the counseling process now could put you in a strong position when medication coverage becomes available.
4. Stay informed. CMS will release more details about the BALANCE Model throughout 2026, including the final list of participating plans, eligible drugs, and enrollment procedures. Monitor Medicare.gov and CMS.gov for updates.
5. Consider your overall Medicare coverage. If you are thinking about switching Part D plans to access the BALANCE Model, make sure the new plan still covers your other medications, uses your preferred pharmacy, and fits your budget for premiums and other cost-sharing.

Important Limitations and Things to Watch

While the BALANCE Model is a major step forward, there are important limitations and uncertainties to keep in mind:

• It is a pilot, not permanent coverage. The BALANCE Model is currently scheduled to end in December 2030. Whether it becomes permanent depends on the results CMS measures during the pilot period. If the model does not demonstrate cost savings or improved outcomes, it could be discontinued.
• Not all plans will participate. Plan sponsors join voluntarily, so coverage will not be universal across all Part D plans. Beneficiaries in areas with fewer participating plans may have limited options.
• Drug supply concerns remain. GLP-1 medications have experienced supply shortages due to overwhelming demand. Expanding coverage to millions of additional patients through the BALANCE Model could put further pressure on supply chains, though manufacturers have been scaling up production.
• Political and legal uncertainty. As with any CMS Innovation Center model, the BALANCE program could face legal challenges or changes due to shifting political priorities. The program's future may depend on the results of the model evaluation and the broader policy environment.
• Long-term medication use. Anti-obesity medications like GLP-1s generally need to be taken continuously to maintain weight loss. If the pilot ends or a beneficiary's plan stops participating, they could lose access to a medication they have come to depend on. This is a consideration CMS will need to address as the model progresses.

How the BALANCE Model Fits Into Your Medicare Coverage

Understanding how the BALANCE Model fits within the four parts of Medicare is helpful for making informed decisions about your coverage. The BALANCE Model operates through Part D, which is the arm of Medicare that covers outpatient prescription drugs. Your Part A (hospital insurance) and Part B (medical insurance) coverage are not affected by the BALANCE Model.

If you currently have a Medicare Advantage (Part C) plan that includes prescription drug coverage (MA-PD), the BALANCE Model can apply to your plan's Part D component if your plan sponsor chooses to participate. If you have Original Medicare with a standalone Part D plan, the same principle applies — your Part D plan sponsor decides whether to participate.

The anti-obesity medications covered under BALANCE are handled outside the standard Part D benefit phases (deductible, initial coverage, coverage gap, and catastrophic coverage). Your $50 copay is fixed and does not change based on which Part D phase you are in for your other medications.

The Bottom Line

For decades, Medicare beneficiaries who needed help managing obesity have been left without drug coverage for some of the most effective medications available. The BALANCE Model represents the first real opportunity for Medicare to cover anti-obesity drugs like Wegovy and Zepbound, making them accessible at a $50 or less monthly copay starting in July 2026.

If you are a Medicare beneficiary living with obesity or overweight with related health conditions, the BALANCE program could be a meaningful change in your coverage. Start by talking to your doctor, reviewing your Part D plan, and staying informed as CMS releases more details about the program. The landscape of Medicare and weight loss drugs is changing — and 2026 may be the year that changes everything.