A planned Medicare pilot program that would have expanded access to popular weight‑loss drugs known as GLP‑1s has been delayed until at least 2027.
The delay was announced this week amid concerns from insurers about costs and uncertainty over how such a program would be implemented.
The pilot, BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth), developed by the Centers for Medicare & Medicaid Services (CMS), was intended to test broader Medicare coverage of GLP‑1 medications.
Why It Matters
GLP-1s are a class of drugs primarily approved for treating Type 2 diabetes but increasingly prescribed for weight loss. Demand for the drugs has surged in recent years.
The delayed pilot was expected to evaluate whether covering GLP‑1 medications could improve health outcomes for Medicare beneficiaries while potentially reducing long‑term costs associated with obesity-related conditions such as diabetes and heart disease.
For beneficiaries, the delay means continued restricted access to these drugs unless they qualify under existing Medicare rules, which primarily apply to diabetes rather than weight loss. That leaves many older adults who might benefit from the medications paying out of pocket.
What To Know
The Trump administration decided to put the pilot on hold after insurers expressed hesitation about participating. Insurers have voiced concerns about the financial risk of covering the high‑priced medications and the lack of clarity regarding long‑term use, patient eligibility, and overall program costs.
“The promises that were made by the administration of drug coverage and the BALANCE pilot program will have to wait,” Kevin Thompson, the CEO of 9i Capital Group and the host of the 9innings podcast, told Newsweek. “If beneficiaries want coverage it looks like out-of-pocket cost may not be capped and will be borne by the patient, not the insurer.”
GLP‑1 drugs can cost thousands of dollars per year per patient, and Medicare’s current coverage rules generally prohibit paying for weight‑loss drugs unless Congress makes a specific exception. While CMS has some authority to test new payment and coverage models through pilot programs, insurer participation is voluntary.
“GLP-1s are already widely used by Medicare and Medicaid beneficiaries as a diabetes drug, and the costs associated already make up an outsized portion of each program’s budget,” Drew Powers, the founder of Illinois-based Powers Financial Group, told Newsweek. “If use was expanded to also include weight loss, the costs could become astronomical.”
UnitedHealthcare, CVS and Eli Lilly all chose not to participate in the CMS program before the April 20 enrollment deadline.
“We’d like to find a path to ‘yes’ there on coverage over time, but there are some notable challenges and outstanding questions with the currently planned structure,” Bobby Hunter, UnitedHealthcare’s CEO of government programs, said during Tuesday’s earnings call about the pilot program. “We’re still working through that process internally.”
What Happens Next
For now, Medicare beneficiaries seeking GLP‑1 medications for weight loss remain largely responsible for paying out of pocket unless the drugs are prescribed for diabetes and covered under existing rules.
Any permanent change to Medicare’s coverage of weight‑loss drugs would likely require congressional action, along with new guidance from CMS.
“It is difficult at this point for doctors and lawmakers to determine if the cost of the drug would be paid for over time by the decrease in obesity-related expenses,” Powers said.