Medicare and GLP-1 medicines: the Bridge, BALANCE and what changes in 2027
Quick answer. Medicare Part D generally cannot cover drugs used for weight loss. Since July 1, 2026, a temporary program called the Medicare GLP-1 Bridge has let some Part D members get Wegovy, the Zepbound KwikPen or Foundayo for $50 a month. CMS extended it through December 31, 2027. The Part D portion of a larger model called BALANCE will not start in 2027, and CMS has not said what follows the Bridge.
Why Medicare did not cover these medicines
Medicare Part D is the drug benefit. By law, a Part D drug cannot be one that Medicaid rules allow programs to exclude, and those rules list drugs used for weight loss. CMS's BALANCE page says Medicare and Medicaid generally do not cover these drugs for the weight loss indication. A medicine can still be covered for a different approved use, such as Wegovy for lowering heart attack and stroke risk in people with heart disease and obesity, or Zepbound for moderate to severe sleep apnea.
The Bridge works around the rule by running outside Part D as a time-limited demonstration. Plans do not take on its cost and do not have to join.
The Medicare GLP-1 Bridge at a glance
| Item | What the program pages say |
|---|---|
| Dates | July 1, 2026 through December 31, 2027. CMS extended the program in an April 21, 2026 memo to plans. KFF reported the earlier end date as December 31, 2026. |
| Medicines | Foundayo tablets, Wegovy (injection or tablet) and the Zepbound KwikPen. Single-dose Zepbound vials and pens are not covered, and CMS's pharmacy page says pen needles are not covered. |
| What you pay | $50 for a one-month supply, which is 28 or 30 days depending on the medicine. |
| What the $50 does not do | It does not count toward the Part D deductible or yearly out-of-pocket limit. Extra Help cannot lower it, the Medicare Prescription Payment Plan cannot spread it out, and coupons cannot be applied to it. |
| Plans that qualify | Standalone drug plans, Medicare Advantage plans with drug coverage (HMO, HMOPOS, and local and regional PPO), Special Needs Plans, employer or union group waiver plans and the LI NET program. CMS lists several other plan types, such as private fee-for-service plans and PACE, as not included unless the person also has a standalone drug plan. |
| Prior authorization | Required. Medicare.gov says an approval is valid, including for refills and dose changes, through December 31, 2027, unless the person switches to a different GLP-1 medicine. |
| How the program is paid for | CMS's memo to plans says participating manufacturers provide the medicines at a net price of $245 per monthly supply. The person pays $50. |
The Atlas read these pages on October 23, 2026. CMS pages carry their own last-modified dates, and program details can change.
Who qualifies, as the program describes it
The program pages say a person must be 18 or older and meet one of the following when they start GLP-1 treatment. The body mass index (BMI) that counts is the one at the start of treatment. The Atlas cannot tell you whether you qualify. A prescriber has to certify the criteria, and CMS can check some details, such as diabetes status, against Medicare records.
| BMI | Plus at least one of |
|---|---|
| 35 or higher | Nothing more is required. |
| 30 or higher | Heart failure with preserved ejection fraction (also called diastolic heart failure), uncontrolled high blood pressure, or chronic kidney disease at stage 3a or higher. |
| 27 or higher | Prediabetes, a previous heart attack or stroke, or peripheral artery disease with symptoms. |
CMS's prior authorization form defines uncontrolled high blood pressure as pressure above the stated limits despite two blood pressure medicines. Check Medicare.gov and the form for exact wording.
Who is not eligible
- People who already get GLP-1 medicines covered through their Part D plan.
- People with type 2 diabetes, moderate to severe sleep apnea or fatty liver disease. Medicare.gov says their Part D plan may still cover GLP-1 medicines. CMS's provider pages use narrower wording for the liver group: noncirrhotic MASH with moderate to advanced scarring.
- People whose prescription is meant to lower the risk of heart attack or stroke. Those go through the Part D plan.
- People under 18, and people without Medicare drug coverage.
How a person gets it, step by step
| Step | What happens |
|---|---|
| The prescriber sends a prescription to the pharmacy | CMS asks for an obesity diagnosis code and a note to send the claim to the Bridge. |
| The pharmacy bills the Bridge | The claim is rejected and signals that prior authorization is needed. |
| The pharmacy asks the prescriber for authorization | This usually happens within 24 to 72 hours. |
| The prescriber submits the request | Through CoverMyMeds or by fax. The prescriber certifies that the medicine is part of a diet and exercise lifestyle program. |
| A decision comes back within 72 hours | A letter goes to the person and the decision goes to the prescriber. |
| The person fills the prescription for $50 | Later fills do not need a new authorization unless the person switches to a different covered medicine. |
CMS says there is no appeals process. A prescriber can resubmit the form with corrected or added information.
How this fits with regular Part D in 2027
CMS lists the conditions on the semaglutide row as type 2 diabetes, and cardiovascular disease with obesity or overweight. The Atlas found no CMS statement that explains how the $274 price relates to Bridge fills, and no statement that 2027 Part D plans will cover these medicines for weight loss. The $50 Bridge copay does not count toward the $2,400 limit.
| Item | 2026 | 2027 |
|---|---|---|
| Yearly out-of-pocket limit on covered Part D drugs | $2,100 | $2,400 |
| Largest deductible a plan may charge | $615 | $700 |
| Medicare-negotiated price for semaglutide (Ozempic, Rybelsus, Wegovy) | Not yet in effect | $274 per 30-day supply, from a 2024 list price of $959. Effective January 1, 2027. |
| Medicare GLP-1 Bridge | Starts July 1 | Runs through December 31 |
Out-of-pocket and deductible figures are from Medicare.gov. The negotiated price is from a CMS fact sheet dated November 2025.
What BALANCE is and what happened to it
BALANCE is a voluntary model from the CMS Innovation Center, announced December 23, 2025. CMS says it will negotiate drug prices and coverage terms with manufacturers for state Medicaid agencies and Medicare Part D plans, alongside lifestyle support. Participation is voluntary for manufacturers, state Medicaid agencies and Part D plans, and CMS says the model does not guarantee coverage for any individual.
The Part D portion was due to begin in 2027. On April 21, 2026, CMS told plans it would delay it for 2027 pending further evaluation and data collection, and would extend the Bridge. CMS says the extension lets it collect data ahead of potential implementation of BALANCE in Part D. The Atlas found no CMS date for a Part D start.
The Medicaid portion is separate. State Medicaid agencies can join from May 2026 through January 1, 2027, and CMS's page names no participating states. Medicaid coverage of these medicines for obesity already varied by state: KFF counted 13 state programs covering them under fee-for-service as of January 2026, after several states dropped coverage in 2025.
How many people could this reach?
KFF says CMS has not published its own estimate of how many people meet the criteria. KFF analyzed 2023 claims and estimated that about 3.8 million Part D enrollees, around 8% of the total, met every criterion. That is KFF's estimate, not a CMS figure.
Officials have also quoted sign-up numbers in speeches. Becker's reported roughly 1.1 million in October from a federal official's remarks. These are spoken figures, and the Atlas found no CMS dataset behind them.
On October 29, 2026, Lilly said on its earnings call that more than half a million people have filled a prescription for a Lilly medicine through the Bridge since July 1. That counts people, not prescriptions, covers Lilly medicines only, and is a company statement. See the Atlas news item and the Eli Lilly tracker.
What to watch out for
- A claim that Medicare covers Ozempic or Mounjaro for weight loss. They are not on the Bridge list. BALANCE's list is wider, but its Part D portion is not starting in 2027.
- A savings card or cash-price offer for someone on Medicare. Maker savings cards generally exclude people in government programs. See the paying for GLP-1 medicines page.
- Assuming the $50 helps you reach your out-of-pocket limit. It does not count toward it.
- End dates. The approval and the program both run through December 31, 2027, and nothing the Atlas found says what happens after.
Quick answers
- Does Medicare cover Wegovy or Zepbound for weight loss?
- Not through the regular Part D benefit, which cannot cover drugs used for weight loss. A temporary program, the Medicare GLP-1 Bridge, covers Wegovy, the Zepbound KwikPen and Foundayo for eligible Part D members from July 1, 2026 through December 31, 2027, for $50 a month.
- How much does the Medicare GLP-1 Bridge cost?
- $50 for a one-month supply. The copay does not count toward the Part D deductible or out-of-pocket limit, and Extra Help cannot lower it.
- Who is eligible for the Bridge?
- The program pages describe adults with a BMI of 35 or higher; a BMI of 30 or higher with heart failure with preserved ejection fraction, uncontrolled high blood pressure or chronic kidney disease stage 3a or higher; or a BMI of 27 or higher with prediabetes, a previous heart attack or stroke, or symptomatic peripheral artery disease. People with type 2 diabetes, moderate to severe sleep apnea or fatty liver disease, and people who already have GLP-1 coverage through their plan, are not eligible. A prescriber and Medicare.gov are the places to check.
- Is the Medicare GLP-1 Bridge ending?
- CMS has extended it through December 31, 2027. The Atlas found no CMS statement about what happens afterward.
- What is BALANCE?
- A voluntary CMS model to negotiate GLP-1 prices and coverage with manufacturers for state Medicaid programs and Medicare Part D plans. CMS delayed its Part D portion for 2027.
- Does the Bridge work with Medicare Advantage?
- Medicare.gov lists Medicare Advantage plans with drug coverage (HMO, HMOPOS, and local and regional PPO) among the eligible plan types. Some other plan types, such as private fee-for-service plans, are not included unless the person also has a standalone drug plan.
- What changes in Part D in 2027?
- Per Medicare.gov, the yearly out-of-pocket limit rises from $2,100 to $2,400 and the largest deductible a plan may charge rises from $615 to $700. Medicare-negotiated prices for semaglutide products also take effect January 1, 2027.
- I have Medicare and Medicaid. Does the Bridge apply?
- CMS says people with both can qualify if they are in an eligible Part D plan type and meet the criteria. Medicaid coverage on its own depends on the state.
Questions to ask
- Do I meet the BMI and health criteria, and what BMI was recorded when I started?
- Is my plan type one the Bridge covers?
- What does the pharmacy need from my prescriber to send the claim to the Bridge?
- What happens to my treatment if the program ends on December 31, 2027?
- Would my Part D plan cover this medicine for another reason, such as type 2 diabetes or sleep apnea?
What is still unknown
- What happens after December 31, 2027. The Atlas found no CMS statement.
- When, or whether, the Part D portion of BALANCE will start. CMS says only potential implementation.
- Whether the processor, the prior authorization process and the $50 amount stay the same in 2027. The CMS pages the Atlas read describe 2026 operations.
- How many people are actually enrolled. Officials have given spoken figures, and on October 29, 2026 Lilly said more than half a million people have filled a Lilly prescription through the Bridge (company-reported, Lilly medicines only). The Atlas found no CMS dataset.
- Which state Medicaid programs have joined BALANCE. CMS lists none.
- How the $274 negotiated price relates to the Bridge, which CMS describes as a separate program with a $245 net price.
- Program rules change. The Atlas read CMS and Medicare.gov pages on October 23, 2026. Check Medicare.gov or call 1-800-MEDICARE.
Sources
- Weight loss drugs (Medicare GLP-1 Bridge) Medicare.gov, the official U.S. government Medicare site. Undated page, read on October 23, 2026. Regulator
- Medicare GLP-1 Bridge Centers for Medicare & Medicaid Services. Program page; CMS showed a last-modified date of July 13, 2026 when the Atlas read it on October 23, 2026. Regulator
- Medicare GLP-1 Bridge: information for providers Centers for Medicare & Medicaid Services. CMS showed a last-modified date of August 6, 2026 when the Atlas read it on October 23, 2026. Regulator
- Medicare GLP-1 Bridge: information for pharmacies Centers for Medicare & Medicaid Services. CMS showed a last-modified date of August 17, 2026 when the Atlas read it on October 23, 2026. Regulator
- Medicare GLP-1 Bridge: expectations and frequently asked questions for Part D sponsors Centers for Medicare & Medicaid Services, memo to Part D plan sponsors dated June 10, 2026. Regulator
- Status update on the Bridge demonstration and the BALANCE model in Part D for contract year 2027 Centers for Medicare & Medicaid Services, memo to Part D plan sponsors dated April 21, 2026. Regulator
- BALANCE Model Centers for Medicare & Medicaid Services, Innovation Center. CMS showed a last-modified date of September 29, 2026 when the Atlas read it on October 23, 2026. Regulator
- Medicare Drug Price Negotiation Program: negotiated prices for initial price applicability year 2027 Centers for Medicare & Medicaid Services fact sheet dated November 2025. Regulator
- Costs for Medicare drug coverage Medicare.gov, the official U.S. government Medicare site. Undated page, read on October 23, 2026. Regulator
- 42 U.S.C. 1395w-102, Providing prescription drug benefits (definition of a covered Part D drug) U.S. Code, Title 42, section 1395w-102. Text as published by the Cornell Legal Information Institute. The Part D definition excludes drugs that Medicaid law lets programs exclude. Regulator
- Social Security Act, section 1927 (payment for covered outpatient drugs) Social Security Administration, compilation of the Social Security Act. Subsection (d)(2)(A) lists agents used for anorexia, weight loss or weight gain among the drugs that may be excluded. Regulator
- Nearly four million Medicare beneficiaries met the eligibility criteria in 2023 for the Medicare GLP-1 Bridge KFF, June 29, 2026. Policy research estimate from 2023 claims data, not a CMS figure. Trade press, secondary source
- Medicaid coverage of and spending on GLP-1s KFF, January 16, 2026. State counts are as of January 2026 and may have changed. Trade press, secondary source
- 1.1 million Medicare beneficiaries signed up for GLP-1 Bridge model Becker's Hospital Review, October 13, 2026, reporting a federal official's remarks at an event. A news report of a spoken figure, not a CMS dataset. Trade press, secondary source
- What Medicare's temporary program covering GLP-1s for obesity means for beneficiaries KFF quick take. Policy research summary; check Medicare.gov and your plan for current rules. Trade press, secondary source
- CMS delays Part D portion of BALANCE model expansion for GLP-1 access American Hospital Association News, April 22, 2026, reporting a CMS memo dated April 21, 2026. News summary; check Medicare.gov and your plan for current rules. Trade press, secondary source