Medicare opens door to covering blockbuster drugs for weight loss

By Tami Luhby, CNN

(CNN) — Some Medicare enrollees may soon be able to access super-popular drugs for obesity under a voluntary model program, the Centers for Medicare and Medicaid Services announced Tuesday. Eligible beneficiaries will have to pay only $50 a month.

Medicare is currently banned by law from covering medications for weight loss, but the administrations of President Donald Trump and former President Joe Biden have argued GLP-1 drugs are crucial to addressing chronic diseases.

The Trump administration recently negotiated a deal with Eli Lilly and Novo Nordisk to provide their weight loss drugs to Medicare at a discounted rate. The model — titled Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth, or BALANCE — aims to improve beneficiaries’ health through greater access to these medications in their Medicare Part D drug plans, along with lifestyle supports, while controlling costs for patients and taxpayers.

The effort builds upon the administration’s goal of “democratizing access to weight-loss medication, which has been out of reach for so many in need,” Dr. Mehmet Oz, CMS administrator, said in a statement. It pairs “breakthrough science with healthy living to cut costs while empowering Americans to take control of their health,” the statement said.

CMS will negotiate prices with the GLP-1 drug makers to provide lower prices under both Medicare and Medicaid, which is administered by states. The negotiations will also cover eligibility criteria for beneficiaries.

Participation will be voluntary for manufacturers, states and Medicare Part D insurers, the agency said.

State Medicaid agencies can join the model in May 2026, and Part D plans in January 2027. But Medicare beneficiaries should be able to access GLP-1s by July through a separate short-term demonstration program. The test will end in December 2031.

The Biden administration last year proposed reinterpreting the law to allow coverage for the treatment of obesity as a chronic disease. Trump administration officials halted that effort earlier this year.

Last month, the Trump administration announced an agreement that calls for eligible Medicare enrollees to pay $50 for certain GLP-1 medications approved for obesity and diabetes and for Medicare to pay $245 for the drugs, which will help pay for the expanded coverage.

Under the agreement, consumers who are overweight and have prediabetes or who have had a stroke or other cardiovascular disease will be eligible, as will those who have obesity and diabetes or uncontrolled high blood pressure and severe obesity.

About 10% of Medicare enrollees would be eligible for expanded access under the deal, senior administration officials said. Medicare already covers certain weight loss drugs if they are also approved to treat certain medical conditions.

The Trump administration noted that the price reductions will make the expansion cost-neutral, while the Biden administration did not include price cuts. The Biden proposal was estimated to cost Medicare $25 billion over a decade.

Eli Lilly and Novo Nordisk also agreed to provide the GLP-1 medications at lower prices to state Medicaid programs, though the timing will depend on negotiations with each state. Sixteen state Medicaid programs reported covering GLP-1s for obesity as of October 1, according to KFF, a nonpartisan health policy think tank. However, some states, such as North Carolina and Michigan, have announced they are dropping or restricting coverage because of the high price tags.

The Alliance of Community Health Plans, which represents local, nonprofit insurers, said it would like to see additional details, including the cost to insurers. It noted in a statement that research has shown GLP-1 medications can improve health outcomes but also comes with side effects that can lead patients to stop taking them within the first year.

“ACHP looks forward to working with the Administration on weight loss therapies that deliver the right treatment, at the right time, at an affordable price,” the alliance said.

More than 70% of adults in the US are considered to have obesity or overweight, increasing the risk for multiple chronic diseases, CMS said.

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