Medicare coverage of GLP-1 drugs has been a slow, partial buildout. Coverage for type-2 diabetes (Ozempic, Mounjaro, Rybelsus, Trulicity) is the long-running standard. Coverage for obesity-only indications (Wegovy, Zepbound) has been more contested — the IRA-driven price negotiations and CMS rulings have moved cautiously even as cardiovascular and renal indications expand the case.
The SELECT trial pushed the conversation forward by giving Wegovy a cardiovascular outcomes label that opens reimbursement under existing CV coverage rules. CMS guidance updates in 2025 and 2026 have parsed exactly which Medicare beneficiaries qualify, with state Medicaid programs mirroring different policies.
Stories here cover CMS rulings, Medicare Part D negotiations, and state Medicaid follow-on decisions. See #cms for direct CMS coverage and #pricing for the broader market context.
After CVS/Aetna, UnitedHealth, and other insurers declined to participate in the BALANCE five-year pilot, CMS announced the Medicare GLP-1 Bridge program — originally scheduled to end December 31, 2026 — will now be extended through 2027 with the federal government directly paying for seniors' obesity drug coverage. The pivot acknowledges that the insurer-funded pilot structure was untenable; CMS said the extension will allow longer data collection on which patients benefit most before any transition back to private payers.
The Trump administration on April 22 cancelled the five-year BALANCE Medicare model that would have had private insurers pay for Wegovy and Zepbound as a regular benefit, after CVS opted out citing a projected $1.4 billion cost over 10 years. Medicare will instead cover the drugs directly through the Medicare GLP-1 Bridge from July 1, 2026 through December 31, 2027, with beneficiaries paying $50/month copays.
Eli Lilly shares closed down nearly 2% at $918.56 and Novo Nordisk fell ~4% on April 22 after CVS Health's decision to opt out of the Medicare obesity drug coverage pilot triggered CMS to scrap the BALANCE model. The combined market cap loss across the two GLP-1 leaders exceeded $25 billion. Hims & Hers dropped another 6% on continued Amazon One Medical competitive pressure.
April 20, 2026 is the CMS application deadline for Medicare Part D plans to participate in the BALANCE Model, which will offer Wegovy, Zepbound KwikPen, and Foundayo at $50 copay with a $245/month net price starting July 1. CMS added Foundayo to the Medicare GLP-1 Bridge on April 6 following FDA approval, extending coverage to Lilly's new oral GLP-1.
NBC News covers Foundayo's approval with self-pay pricing from $149-$349/month across six dose tiers. Medicare coverage for some patients could begin as early as summer 2026 with copays as low as $50/month.
CMS confirmed that Medicare Part D beneficiaries will gain access to Wegovy and Zepbound for weight loss through the Medicare GLP-1 Bridge program starting July 2026 at a $50 monthly copayment, bridging to the full BALANCE Model launching in Medicare Part D in January 2027.