For the estimated 35 million Medicare beneficiaries struggling with obesity and related health conditions, a new federal program announced late last year represents nothing short of a healthcare revolution. The BALANCE program—Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth—will enable Medicare Part D plans to cover GLP-1 medications used for weight management at a patient cost of just $50 per month.

A Historic Policy Shift

Historically, Medicare has been prohibited by statute from covering weight loss drugs. This restriction, rooted in legislation from decades past, has left millions of older Americans unable to afford breakthrough obesity treatments that can cost over $1,000 per month out of pocket.

The Trump Administration's new policy creates a path around this restriction through a voluntary model program. While the administration initially rejected the Biden Administration's proposed rule for broad obesity drug coverage in April 2025, the BALANCE program represents a more targeted approach that still dramatically expands access.

"This program enables Medicare Part D plans and state Medicaid agencies to cover GLP-1 medications used for weight management and metabolic health improvement, while helping control costs."

— Centers for Medicare and Medicaid Services

Who Qualifies

The program isn't universal—it targets Medicare beneficiaries with the highest medical need:

  • Those with a BMI of 27 or higher who have prediabetes or a history of cardiovascular disease
  • Those with a BMI over 30 who have heart failure with preserved ejection fraction
  • Those with obesity combined with uncontrolled high blood pressure
  • Those with severe obesity and chronic kidney disease

CMS estimates this expanded coverage will reach approximately 10% of Medicare beneficiaries—roughly 6.5 million people initially, with potential for expansion based on program results.

The Timeline

The rollout unfolds in phases:

  • July 2026: Medicare Part D beneficiaries gain access through a short-term demonstration program serving as a bridge to BALANCE
  • January 2027: Full BALANCE program launches for Medicare Part D
  • May 2026: Medicaid coverage launches in participating states
  • December 2031: Initial program period ends, with evaluation determining continuation

The $50 Question

Under the agreement, eligible beneficiaries will pay $50 per month for covered GLP-1 medications, with Medicare paying approximately $245. This represents savings of 75-90% compared to retail prices for drugs like Wegovy, Mounjaro, and Zepbound.

The covered medications include:

  • Injectable Wegovy (semaglutide)
  • Injectable Ozempic (semaglutide, for diabetes indication)
  • Injectable Mounjaro (tirzepatide)
  • Injectable Zepbound (tirzepatide)
  • Oral Wegovy (recently FDA-approved pill form)

Healthcare System Implications

The potential healthcare savings dwarf the cost of the drugs themselves. Obesity is linked to over 200 medical conditions, including type 2 diabetes, heart disease, certain cancers, and joint problems. Medicare currently spends hundreds of billions annually treating these obesity-related conditions.

Clinical trials have shown GLP-1 medications can produce weight loss of 15-25% of body weight, with corresponding reductions in cardiovascular events, diabetes progression, and other obesity-related complications. If these results translate to the Medicare population, the program could generate substantial long-term savings.

What It Means for Your Wallet

For eligible beneficiaries, the math is straightforward. Current options for obtaining GLP-1 medications include:

  • Retail cash price: $900-$1,400 per month
  • Manufacturer savings cards: $500-$600 per month (limited availability)
  • Compounded versions: $200-$500 per month (quality concerns)
  • New BALANCE program: $50 per month

The $50 monthly cost makes these medications accessible to fixed-income seniors for the first time, potentially transforming obesity treatment among older Americans.

Challenges Ahead

The program faces several implementation challenges:

  • Supply constraints: Eli Lilly and Novo Nordisk have struggled to meet existing demand; adding millions of Medicare beneficiaries will strain supply chains further
  • Plan participation: The program is voluntary, meaning not all Medicare Part D plans may participate initially
  • Eligibility verification: Confirming beneficiaries meet medical criteria requires coordination between CMS, plans, and healthcare providers
  • Long-term sustainability: If demand exceeds projections, program costs could balloon beyond initial estimates

Taking Action

For Medicare beneficiaries interested in accessing GLP-1 medications through BALANCE, preparation should begin now:

  1. Talk to your doctor: Discuss whether you might qualify based on the eligibility criteria
  2. Document your conditions: Ensure your medical records reflect relevant diagnoses (prediabetes, cardiovascular history, etc.)
  3. Review your Part D plan: Confirm with your plan whether they intend to participate in the BALANCE program
  4. Consider timing: The demonstration program launches in July 2026—plan accordingly

The Bigger Picture

The BALANCE program represents more than just drug coverage—it signals a fundamental shift in how the healthcare system approaches obesity. For decades, obesity was treated as a lifestyle choice rather than a medical condition. The emergence of effective pharmaceutical treatments, combined with policy changes like BALANCE, marks a new era in obesity medicine.

For the millions of Americans who have struggled with weight their entire lives, help may finally be on the way—and at a price they can actually afford.