Medicare GLP-1 Coverage: BALANCE Model Explained

What Is the BALANCE Model?

The BALANCE (Benefitting Adults through Lifestyle and Nutrition Care Enhancement) Model is a Centers for Medicare & Medicaid Services (CMS) initiative that will provide Medicare beneficiaries access to GLP-1 medications for weight management at significantly reduced costs.

For the first time ever, Medicare will cover Wegovy and Zepbound specifically for weight loss—not just for diabetes. This represents a massive policy shift that could benefit millions of older Americans struggling with obesity.

Who Qualifies?

Eligibility is based on your BMI combined with specific obesity-related health conditions:

Timeline: What to Expect

How to Prepare Right Now

1. Document your BMI. Schedule an appointment with your doctor to get your current weight and height on record. Multiple measurements over time strengthen your case.

2. Get qualifying conditions documented. If you have prediabetes, cardiovascular disease, heart failure, hypertension, or CKD, ensure these diagnoses are clearly noted in your medical records with proper ICD-10 codes.

3. Talk to your doctor about GLP-1s. Start the conversation now. Your provider can help determine if you're a good candidate and prepare the necessary documentation.

4. Keep records of previous weight loss attempts. Documentation of diet programs, exercise regimens, or other medications you've tried can support your case for GLP-1 therapy.

Current Medicare Options (Before July 2026)

Until the BALANCE Model launches, Medicare coverage for GLP-1s remains limited:

For diabetes (covered now): Ozempic and Mounjaro are covered under Medicare Part D when prescribed for type 2 diabetes. Copays vary by plan but are typically $50-150/month with coverage.

For weight loss (NOT covered until July 2026): Wegovy and Zepbound are explicitly excluded from Medicare Part D for weight loss indication. The BALANCE Model changes this.

What About Compounded GLP-1s?

Some Medicare beneficiaries have turned to compounded semaglutide or tirzepatide from telehealth providers as a workaround. These typically cost $149-399/month out-of-pocket.

However, compounded medications are NOT FDA-approved and are not covered by Medicare. If you choose this route, you'll pay entirely out-of-pocket with no reimbursement.

For most Medicare beneficiaries, waiting for the BALANCE Model (July 2026) or qualifying through a diabetes diagnosis may be more cost-effective long-term.

The Numbers: Why This Matters

Consider the cost comparison for a Medicare beneficiary:

Option	Monthly Cost	Annual Cost
Wegovy retail (no coverage)	$1,349	$16,188
Compounded semaglutide	$149-299	$1,788-3,588
BALANCE Model (July 2026)	$50	$600

The BALANCE Model offers savings of $15,588/year compared to retail pricing and remains more affordable than even compounded alternatives.