Question from Irma: Can you shed some light on Medicare covering GLP-1 drugs for weight loss like Wegovy and Zepbound? I know they’re not currently available, but I heard they will be soon.

Answer: This following is what I pulled from Google AI, which is in line with my understanding based on research and reading I’ve done. I’ll share some other information, my predictions and opinions on what we might expect as the rollout begins later this year and expands in 2027. 

Yes, Medicare is expected to begin covering GLP-1 drugs for weight loss in mid-2026 through a new demonstration program, following a deal with manufacturers to lower prices, with eligible beneficiaries potentially paying around $50 monthly, though coverage will be limited to specific patient groups with obesity-related conditions and will depend on plan participation. This is a shift from prior policy, enabling coverage beyond just diabetes, with plans to transition into the long-term “BALANCE” model in 2027. 

Key Details for 2026 Coverage

• Start Date: A bridge program launches in July 2026, with the broader BALANCE model starting in 2027. 
• Eligibility: Coverage will be for specific patient groups, including those with obesity, with a Body Mass Index (BMI) over 30 and related conditions like heart disease, hypertension, or kidney disease, and overweight individuals (BMI > 27) with prediabetes or cardiovascular issues. 
• Cost: Beneficiaries could pay around a $50 copay per month due to negotiated price reductions with drugmakers. 
• Drugs Covered: This includes popular GLP-1s like Ozempic, Wegovy, Mounjaro, and Zepbound, as well as new oral forms. 
• Conditions: Coverage expands beyond diabetes to include weight management when paired with other health conditions. 
• Participation: Coverage depends on drug manufacturers, states, and Part D sponsors voluntarily joining the demonstration. 

Let me personally add that as of right now, many of these medications are already covered for the following: 

• Type 2 Diabetes: Ozempic, Mounjaro, and Rybelsus are covered if prescribed for Type 2 diabetes, as this is a primary FDA-approved use.
• Cardiovascular Risk: Wegovy (semaglutide) can be covered for reducing cardiovascular risk in patients with established heart disease and obesity/overweight.
• Sleep Apnea: Zepbound (tirzepatide) may be covered for adults with obesity and obstructive sleep apnea, if the plan lists it. 

Anyone who currently has diabetes can get prescribed those meds quite easily. However, be advised those diagnosed with sleep apnea or who are obese with chronic heart disease will need documentation from the prescribing physician to their Part D or Advantage Plan company stating that the condition exists and why Zepbound or Wegovy is medically necessary prior to those drugs being covered. 

I also want to warn people that I don’t think the rollout is going to be smooth and not to expect to get these drugs covered right away on June 1^st. 

As stated above, it will depend on plan participation, which is voluntary. I don’t expect many companies to raise their hands volunteering to pay out tens or hundreds of millions more dollars in claims this year. It’s also not clear right now if participation is going to be mandatory for Stand Alone Part D and Advantage Plan companies in 2027.

Regardless, if you feel you’re a candidate and will qualify, I recommend starting to have the initial discussion with your primary care doctor or specialist in preparation. Even when they are covered, you may need to be patient as I expect prescribing doctors to be very busy, possibly overwhelmed as the number of people who want to use these medications and will likely qualify to be staggering. 

Here are some statistics: 

• 30% of Americans over the age of 65 have a Body Mass Index (BMI) over 30, which is considered obese. 66% have a BMI over 25, considered overweight. 
• 40% of all American adults have a BMI over 30 while 74% are over 25! 

I speculate that many, if not most, have one or more of the underlying conditions that would allow them to qualify. Pre-diabetes is diagnosed by having a fasting blood glucose of just 100-125 mg/dL, or an A1C level of 5.7% to 6.4%.

I’m extremely concerned about the cost of the program to taxpayers and the stress it will put on Original Medicare along with Part D and Advantage Plan insurance companies. We already have the new Maximum Out of Pocket limit for covered drugs for those on Medicare Part D that was introduced in 2025. That expense to Medicare was gigantic. The BALANCE program will exclude GLP-1 drugs from deductibles unlike most other brand name medications. And with possibly as many as 25% of everyone on Medicare taking a GLP-1 in the next few years, BALANCE, combined with the cost of the Maximum Out of Pocket regulations, is going to add hundreds of billions of dollars a year in new liability for Medicare and insurance companies. 

I predict the result will be much higher premiums for Medicare Part B and Stand-Alone Prescription Drug plans, along with increased premiums, co-pays, and MOOP on Advantage Plans as well the reduction of the “extras,” that have made HMOs and PPOs so popular. In the short term, the new qualifications and lower co-pays may sound great for those who are currently on or want to take a GLP-1, but over the next three to ten years, the increased expenses to insurance companies and the federal government will have to be passed on to consumers and taxpayers. Hopefully, as people lose weight, they will become healthier in other areas, offsetting some of the costs. However, I believe it will take quite a long time to see any savings in that regard.

We will continue to monitor the BALANCE program moving forward and keep everyone informed as we learn more. 

With questions regarding this column or any other Medicare related topic, or if you would like to make an appointment for a no-cost consultation to, give the office a call, 724-603-3403, or email me personally, Aaron@GetYourBestPlan.com.