What Is This Program?
Medicare is starting a short-term pilot program to cover GLP-1’s prescribed for weight loss. This program called the “Medicare GLP-1 Bridge” or BALANCE Model.
Who Can Join the Pilot Program?
This program is for people who meet certain prior authorization criteria (high body mass index and/or specific weight-related health conditions). You must also be enrolled in a standalone prescription drug plan (PDP) or Medicare Advantage plan with prescription coverage (MA-PD).
When Does It Start?
Medicare will operate the short-term pilot from July 1, 2026, until December 31, 2027.
How Does It Work?
Unlike standard prescription benefits, this temporary program bypasses traditional Part D/MA-PD plans. Instead, it uses a centralized authorization system. A beneficiary’s doctor will submit a prior authorization and prescription for an eligible GLP-1, for weight loss, to a central system run by Humana. Humana will review the submission and either approve or deny it.
What Will It Cost?
If approved, the patient will pay a set $50 copay at the pharmacy when they pick up their prescription. This $50 copay does not change even if dosages increase or decrease.
Which Drugs Are Covered?
Per CMS guidance from May 1, 2026, covered prescriptions will include:
- Foundayo,
- Wegovy (injections and tablets), and
- Zepbound (KwikPen only).
(Single-dose vial and single-dose pen formulations of Zepbound are not available.)
Will It Count Toward My Deductible?
While the program makes weight loss prescriptions much more affordable, any payments for these prescriptions will not count toward the $2,100 out of pocket annual prescription cap. It also will not count toward your drug plan’s deductible. Additionally, there is no price break for people receiving LIS (also called Extra Help). They must also pay the $50 monthly copay.
What If I’m Already Taking a GLP-1?
Anyone taking a GLP-1 for a condition not related to weight loss (such as Type 2 diabetes, sleep apnea, etc.) will continue to receive their prescription through their Part D plan, and pay the prices set by their plan.
What Happens When the Pilot Program Ends?
At this time there is no information about extending this program after December 2027.
Where Can I Find More Information?
Medicare has a website with up-to-date information about the Medicare GLP-1 Bridge Program.