Medicare’s New GLP-1 Coverage Model Explained
What the New BALANCE Model Could Mean for GLP-1 Coverage
Access and cost remain two of the biggest questions surrounding GLP-1 medications like Wegovy, Zepbound, Ozempic, and Mounjaro. A new federal program called the BALANCE Model aims to test whether expanding coverage for these medications can improve health outcomes while managing long-term healthcare costs.
Let’s walk through what this program is, who it may help, and what it might mean for people living with obesity or related health conditions.
What Is the BALANCE Model?
The BALANCE Model is a new Medicare and Medicaid demonstration program from CMS (Centers for Medicare & Medicaid Services) designed to improve access to certain GLP-1 medications.
The program is still in the early stages, but the overall goal is to test whether making these medications more affordable and accessible can improve health outcomes while managing healthcare costs.
This model will run from 2027 through 2031 if enough Medicare drug plans decide to participate.
Right now, CMS is inviting Medicare Part D plans and state Medicaid programs to apply to participate.
When Would This Start?
Here’s the general timeline so far:
• March 2026 – Applications opened for Medicare drug plans
• April 2026 – Deadline for plans to apply
• September 2026 – Participating plans are expected to be announced
• January 1, 2027 – Program begins
• December 31, 2031 – Program scheduled to end
It’s important to know that the program will only move forward for Medicare if enough plans choose to participate.
Which Medications Are Included?
The model currently includes several GLP-1 medications used for diabetes and weight management, including:
• Mounjaro
• Ozempic
• Rybelsus
• Wegovy
• Zepbound (KwikPen version)
A new oral medication, orforglipron, could also be included if it receives FDA approval.
These medications may be covered for diabetes and certain weight-related conditions, depending on eligibility.
What Could the Cost Be?
One of the most talked-about parts of the program is the potential cost structure.
For many Medicare beneficiaries in participating plans:
• Monthly cost could be capped around $50 after the deductible is met
Before the deductible is reached:
• Costs may be limited to about $245 per month plus a dispensing fee
Actual costs will still depend on individual insurance plans and whether the plan participates in the program.
Who Might Qualify?
Eligibility will still require confirmation from a healthcare provider.
Patients may qualify if they meet certain health criteria along with BMI thresholds.
Examples include:
• BMI ≥ 35
• BMI ≥ 30 with conditions like high blood pressure, sleep apnea, kidney disease, or heart failure
• BMI ≥ 27 with conditions such as prediabetes or previous cardiovascular events (like heart attack or stroke)
People with type 2 diabetes or certain forms of fatty liver disease may also qualify.
These criteria are designed to focus on individuals with higher medical risk related to obesity.
What About Nutrition and Lifestyle Support?
Lifestyle support is included in the BALANCE model — which is important. But in my dietitian opinion, this is also one of the more unclear parts of the program.
The model requires that patients receiving these medications participate in lifestyle support. A provider simply needs to confirm that support is part of the treatment plan, which could include nutrition counseling, coaching, education, or structured programs.
Drug manufacturers may also offer lifestyle programs connected to their medications.
However, the model does not specifically require Medical Nutrition Therapy with a registered dietitian, even though obesity is a complex chronic disease that often benefits from individualized nutrition care.
Patients in the program could still work with dietitians or other clinical support teams — and many would likely benefit from that level of guidance.
What If Someone Is Already Taking a GLP-1?
If you are already using one of these medications and meet the program’s eligibility requirements, you may be able to receive the medication at a lower cost if your Medicare or Medicaid plan participates in the model.
Details will depend on the specific insurance plan.
What Happens Next?
Over the next several months, we’ll learn:
• Which Medicare drug plans choose to participate
• Whether the participation threshold is met
• How individual plans implement coverage and prior authorization
Healthcare providers and advocacy groups will also be watching closely to see how the program affects patient access, affordability, and long-term health outcomes.
My Take as a Dietitian
If there is one thing I want patients to hear consistently, it’s this:
Medication is a powerful tool for long-term obesity care, but it works best when it’s part of a larger plan that supports nutrition, behavior change, and overall health.
Programs like this acknowledge something many patients already know — obesity is a chronic disease that deserves ongoing treatment and support.
The conversation around treatment options is continuing to evolve, and programs like BALANCE are one step in that process.
As more information becomes available, I’ll continue sharing updates and helping translate the policy language into what actually matters for patients.
Continue this conversation, the Secret Podcast
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I walk through what’s actually changing, what to watch for, and how to make decisions about medications, nutrition, and long-term care in a way that fits real life.