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Medicare changes coverage for weight-loss drugs

By: Ken Alltucker
USA Today

..... Medicare has delayed a program for older Americans that would've require participating insurance companies to cover GLP-1 weight-loss drugs such as Novo Nordisk's Wegovy and Eli Lilly's Zepbound.
..... But that doesn't mean Medicare enrollees will go without these popular drugs. Medicare will offer the drugs through a bridge program form July 1. 2026, through December 31, 2017, according to a spokesperson for the Centers for Medicare & Medicaid Services.
..... The bridge program will allow enrollees in Medicare, the federal health program for adults 65 and older to get weight-loss drugs at prices negotiated under President Donald Trump's most favored nation agreement with Eli Lilly and Novo Nordisk.
..... Medicare enrollees will pay a 450 monthly copay to get the mediations, according to Lilly and Nordisk officials.
..... The change will allow Medicare beneficiaries access to certain GLP-1 medication "outside of the Medicare Part D benefit coverage and payment flow," CMS said.
..... The change came after multiple insures expressed concerns about the voluntary BALANCE (Better Approaches to Ll Lifestyle and Nutrition for Comprehensive Health) program that would've required Part D insures to cover the medication. Insures had until April 20 [2026] to commit to the program.
..... CVS Health, which owns Aetna, said it chose not to opt in on the BALAMCE program. IN UnitedHealth's earnings call on April 21, [2026] a company official cited "notable challenges and outstanding questions" about the program.
..... CMS announced the BALAMCE program at the end of 2025 as a way for Medicare and state Medicaid plans to bypass a prohibition on covering weight-loss treatments. The BALANCE program also would've changed Medicare enrollees a $50 monthly copay to get the weight-loss drugs.
..... CMS said the Medicaid portion of the BALANCE program will application open to states trough July 31, 2026. Medicaid is jointly funded by the federal government and states, which directly manage state Medicaid programs under federal guidance.
..... Lilly, which sells the popular GLP-1 injectable weight-loss drug Zepbound and the weight-loss pill Foundayo, applauded CMS's decision to launch a bridge program amid insure uncertainly.
..... A Lilly spokespersons said the company "advocates the long-term vision of the BALANCE model" but added the bridge program will reach patients who can benefit by GLP-1 drugs.
..... A Novo spokespersons said the company would support the bridge program while working on long-term access for America's seniors.
..... The extension of the bridge program through 2027 ease uncertainly around reimbursement for weight-loss drugs and blunts any near-term impact on demand, but an indefinite delay raises doubt on permanent integration into Medicare prescription drug plans, analysts said.
..... In the loner term, "once this obesity benefit is established, we believe it will be practically politically difficult top roll back as we look toward 2028 and beyond," J.P.Morgan analyst Chris Schott said, according to Reuters.

..... Contributing: Reuters

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