Update: CMS and Eli Lilly Release New Details on Medicare GLP-1 Coverage Pilot

UPDATED 3/10/26: Patient eligibility requirements have been outlined and can be found at the bottom of this article.

The question I have been hearing repeatedly since early January is straightforward. Will Medicare actually start covering GLP-1 medications this summer? New documents from the Centers for Medicare & Medicaid Services, along with a statement from Eli Lilly, suggest that something meaningful could begin in July of 2026, but it is not quite what many people expected. What the federal government appears to be preparing is a temporary bridge program that could allow some Medicare beneficiaries to access medications such as Zepbound for about fifty dollars per month before a larger coverage experiment known as the BALANCE Model begins in 2027. Understanding how those two programs connect is key to understanding where GLP-1 access for Medicare patients is actually headed.

Back in early January here on On The Pen, I wrote that the federal government was quietly constructing a pathway to test Medicare and Medicaid coverage of GLP-1 medications for obesity and metabolic disease through the BALANCE Model. At that time the outline was visible but many of the operational details had not yet surfaced. CMS had introduced the voluntary pilot structure, negotiations tied to Most Favored Nation pricing pressure had begun to reshape expectations around what these drugs might cost in federal programs, and the agency had hinted that a separate Medicare demonstration might begin in the summer of 2026. What remained unclear was how the programs would actually function for patients navigating the Medicare system.

Today, implementation materials from CMS and new comments from Lilly begin to fill in that picture. The documents suggest that the federal government is preparing a two phase rollout that allows GLP-1 medications to move into the Medicare ecosystem without Congress first rewriting the statute that currently excludes drugs used solely for weight management.

The first phase would arrive through what CMS has described as the Medicare GLP-1 Bridge Model. According to the available information, this demonstration is expected to begin on July 1, 2026 and run through the end of this year. During that 6 month period eligible Medicare beneficiaries could gain access to certain GLP-1 medications for roughly $50 per month and without a deductible requirement. The structure differs significantly from traditional Medicare drug coverage. Instead of routing coverage through the standard Medicare Part D benefit, the bridge model would be administered directly by CMS, with the federal government negotiating pricing with manufacturers and managing payment flows during the demonstration period.

That structural design addresses one of the biggest barriers that has historically prevented Medicare plans from embracing obesity medications. Under the normal Part D framework, insurance plans carry significant financial risk when covering high demand drugs with large patient populations. By temporarily removing that risk from the plans and shifting price negotiation directly to the federal government, CMS is attempting to create conditions where plans are more willing to participate in the experiment.

The second phase of the rollout would begin on January 1, 2027 with the launch of the BALANCE Model itself. BALANCE is designed as a voluntary Medicare Part D model intended to test whether GLP-1 medications can be integrated into the drug benefit at scale while maintaining predictable spending for the federal government. Under the framework outlined by CMS, participating plans would cover medications from participating manufacturers at a negotiated government price structure. Public reporting around the administration’s pricing negotiations suggests that the underlying government price for many injectable GLP-1 medications participating in the model could be around $245 per month.

For patients, however, the number that matters most is the out of pocket cost rather than the government negotiated supply price. After beneficiaries move beyond the Part D deductible, most patients in participating plans are expected to see monthly out of pocket costs around $50. Before the deductible is met, cost sharing could reach roughly $245 plus a dispensing fee. It is also important to note that the $50 figure applies to most but not all participating plans. Some basic Medicare Part D plans could require higher cost sharing depending on their structure.

In its public statement, Lilly confirmed that several of its medicines are expected to participate in the program. These include Zepbound, Mounjaro, and the investigational oral GLP-1 Orforglipron, assuming the latter receives regulatory approval. CMS implementation documents also reference drugs produced by Novo Nordisk, including Wegovy, Ozempic, and Rybelsus, though final participation will depend on manufacturer agreements and the decisions made by participating Medicare plans.

Even with these developments, it is important to understand why the programs are being structured in this particular way. Medicare does not currently include obesity medications as a covered benefit under federal law. Congress has debated legislation such as the Treat and Reduce Obesity Act for years but has not enacted it. Because of that constraint, CMS is operating through the authority of the CMS Innovation Center, which allows the agency to run temporary models and demonstrations testing new payment and coverage approaches. Both the bridge program and the BALANCE Model fall under that authority. These programs allow the federal government to evaluate utilization patterns, health outcomes, patient adherence, spending, and beneficiary experience without making a permanent change to Medicare statute.

Several details still remain unresolved. CMS has not finalized the clinical eligibility criteria that will determine which beneficiaries qualify for participation in either the bridge program or the BALANCE Model. Enrollment mechanics have not yet been fully described, and the lifestyle and nutrition support components tied to the BALANCE framework remain under development. Participation by manufacturers and Medicare plans is also voluntary, meaning access could vary depending on which plans ultimately choose to join the program.

Advocacy organizations such as our friends at the Obesity Action Coalition have welcomed the signal that federal policymakers are exploring new approaches to obesity treatment while also cautioning that these pilots should not be interpreted as immediate nationwide coverage. The voluntary structure means the real world impact will depend heavily on how many plans and manufacturers ultimately participate.

What makes this moment different from previous policy discussions around obesity medications is the level of alignment that appears to be emerging among the major stakeholders in the system. The federal government is seeking predictable pricing and ways to control spending growth. Drug manufacturers are interested in expanding access to millions of additional patients through federal programs. Insurance plans want protection from the unpredictable financial exposure that large populations of patients using high demand drugs can create. The current structure attempts to balance those incentives through negotiated pricing and pilot programs designed to generate real world evidence.

Whether that balance holds will determine the future of obesity treatment coverage within Medicare. The bridge program expected in the summer of 2026 represents the first real test of how this policy works in practice. The BALANCE Model scheduled for 2027 will determine whether those early results can evolve into a broader and more durable pathway for GLP-1 medications inside the federal health system.

UPDATE (eligibility requirements added):

Basic eligibility

• Must be 18 or older

• Must be enrolled in Medicare with Part D drug coverage (standalone PDP or Medicare Advantage drug plan)

• Program is nationwide

BMI based eligibility

You qualify if one of these applies:

1. BMI ≥ 35

OR

2. BMI ≥ 30 plus one of these conditions

• Heart failure with preserved ejection fraction

• Uncontrolled hypertension despite treatment

• Chronic kidney disease stage 3a or higher

OR

3. BMI ≥ 27 plus one of these

• Prediabetes

• Previous heart attack

• Previous stroke

• Symptomatic peripheral artery disease

Other requirements

• Medication must be prescribed for weight loss and weight maintenance

• Must be used with ongoing lifestyle modification (diet + physical activity)

• A doctor must submit a prior authorization to a CMS central processor

Drugs currently included

• Zepbound

• Wegovy

Cost during the bridge program

• $50 per month copay

• Runs July 1 – December 31, 2026

Important limitations

• Not available to people in PACE, certain cost plans, or private fee-for-service plans unless they also have a standalone Part D plan

• Must transition to a BALANCE participating Part D plan in 2027 to continue coverage