Medicare’s New $50 Weight Loss Drug Option Explained

Medicare’s New $50 Weight Loss Drug Plan: What Seniors Need to Know

Estimated reading time: 5 minutes

Key Takeaways

• Medicare is piloting a new BALANCE model that could give some beneficiaries access to GLP-1 weight loss drugs like Wegovy for about $50 per month.
• Federal law still bans Medicare from broadly covering weight loss drugs, but both the Trump and Biden administrations have pushed GLP-1s as tools to fight chronic diseases.
• The Trump administration negotiated discounted prices with Eli Lilly and Novo Nordisk, aiming to make the expansion cost-neutral for Medicare.
• Roughly 10% of Medicare enrollees could qualify under the new eligibility rules focused on obesity, diabetes, cardiovascular disease, and high blood pressure.
• States can opt in for Medicaid starting in 2026, but some have already cut coverage because of high drug costs.

Table of Contents

• How Medicare and Weight Loss Drugs Got Here
• Inside the BALANCE Model: What It Offers
• Costs, Eligibility, and Who Qualifies
• What This Means for Medicaid and States
• Benefits, Risks, and Realistic Expectations
• Practical Next Steps for Medicare Beneficiaries

How Medicare and Weight Loss Drugs Got Here

Under current federal law, Medicare cannot generally cover drugs used solely for weight loss. Yet a new class of medications called GLP-1 receptor agonists (such as Wegovy and similar drugs) has transformed how clinicians think about obesity, shifting it from a lifestyle issue to a chronic disease that can be medically treated.

Both the Trump and Biden administrations have framed GLP-1s as critical for tackling chronic conditions like obesity, diabetes, and heart disease. The Biden team proposed reinterpreting the law to treat obesity as a chronic disease eligible for coverage, but Trump administration officials halted that effort in 2025.

Instead, the Trump administration turned to a different lever: negotiating prices directly with drug manufacturers and building a voluntary Medicare model around those agreements.

Inside the BALANCE Model: What It Offers

The new initiative is called Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE). It is designed as a Medicare Part D model that combines:

• Access to GLP-1 medications at reduced cost
• Structured lifestyle support (nutrition, physical activity, and behavior change)
• Cost controls for both patients and taxpayers

According to CMS Administrator Dr. Mehmet Oz, the model aims to “democratize access to weight-loss medication, which has been out of reach for so many in need,” by pairing “breakthrough science with healthy living.”

Key design features include:

• Voluntary participation by drug manufacturers, states, and Medicare Part D plans
• Price negotiations between CMS, Eli Lilly, and Novo Nordisk for lower GLP-1 prices
• A test period running through December 2031

While the full BALANCE model starts later, Medicare beneficiaries are expected to gain access to GLP-1s as early as July through a short-term demonstration program.

Costs, Eligibility, and Who Qualifies

For eligible beneficiaries, the headline number is striking: $50 per month out-of-pocket for certain GLP-1 medications used for obesity and diabetes. Under a recent agreement:

• Beneficiaries pay about $50
• Medicare pays about $245 per prescription

This heavily discounted price is what allows the Trump administration to argue the expansion will be cost-neutral, in contrast to the Biden proposal, which was projected to cost Medicare $25 billion over 10 years without price cuts.

Who may be eligible? The agreement envisions coverage for people who meet specific health criteria, including:

• Consumers who are overweight with prediabetes
• Those who are overweight and have had a stroke or other cardiovascular disease
• People with obesity and diabetes
• Individuals with uncontrolled high blood pressure and severe obesity

Senior administration officials estimate that about 10% of Medicare enrollees could qualify for this expanded access. Medicare already covers some GLP-1s when they are approved for other conditions (like diabetes or cardiovascular risk reduction), but this model significantly widens access for obesity-related use.

What This Means for Medicaid and States

The pricing deals struck with Eli Lilly and Novo Nordisk go beyond Medicare. The manufacturers also agreed to make GLP-1 drugs available to state Medicaid programs at reduced prices.

However, Medicaid participation is not automatic:

• State Medicaid agencies can opt into the model starting in May 2026.
• Exact pricing and eligibility will be determined through state-by-state negotiations.

As of October 1, 16 state Medicaid programs reported covering GLP-1s for obesity, according to the nonpartisan health policy think tank KFF. Yet, states like North Carolina and Michigan have announced they are dropping or restricting coverage due to high costs.

For readers on Medicaid, it will be important to:

• Monitor announcements from your state Medicaid agency
• Ask your health plan whether GLP-1s for obesity are covered today or may be covered under the new model in 2026 and beyond

Benefits, Risks, and Realistic Expectations

More than 70% of US adults are classified as overweight or having obesity, which greatly increases the risk for conditions such as diabetes, heart disease, and stroke. GLP-1 medications have been shown to:

• Support clinically meaningful weight loss
• Improve certain cardiometabolic outcomes

At the same time, they are not a magic bullet. The Alliance of Community Health Plans (ACHP), which represents nonprofit local insurers, has asked for more detail on cost structures and emphasized the importance of balancing outcomes with affordability.

Research cited by ACHP shows that while GLP-1s can offer strong benefits, they also come with side effects—such as gastrointestinal symptoms—that lead some patients to stop treatment within the first year.

For best results, experts stress that GLP-1s should complement, not replace, evidence-based lifestyle changes in diet, exercise, and sleep.

For readers considering treatment, a practical approach is to view GLP-1s as part of a broader health plan that includes:

• Nutrition counseling and sustainable meal planning
• Gradual, physician-approved physical activity
• Regular monitoring of blood pressure, blood sugar, and cardiovascular risk

Practical Next Steps for Medicare Beneficiaries

If you or a loved one is on Medicare and struggling with obesity or related conditions, here are simple action steps:

• Talk to your doctor: Ask whether you meet the clinical criteria (overweight with prediabetes, prior stroke, cardiovascular disease, obesity with diabetes, uncontrolled high blood pressure with severe obesity).
• Review your Part D plan: Contact your plan’s customer service to ask how and when they will participate in the new model or demonstration program.
• Track timing: Look for potential access to GLP-1s starting around July under the short-term demonstration, with broader BALANCE implementation for Part D plans in January 2027.
• If you’re on Medicaid: Check your state’s website regularly as 2026 approaches to see whether it opts into the negotiated pricing model.

To go deeper, you may want to:

• Explore independent resources from organizations like KFF and ACHP to understand coverage trends and safety data.
• Compare lifestyle programs (online or in-person) that integrate nutrition, physical activity, and behavioral support alongside medication.

As policies evolve, this initiative could mark a major shift in how the US health system addresses obesity—moving from exclusion and high out-of-pocket costs toward more structured, affordable coverage for those at highest medical risk.

Source: https://www.cnn.com/2025/12/23/politics/weight-loss-drugs-medicare