Medicare Just Started Covering Ozempic and Wegovy for Weight Loss. Here’s Who Qualifies, What It Costs, and What Most Beneficiaries Still Don’t Know.

WASHINGTON, May 1, 2026 —

Key Takeaways

• Medicare Part D plans participating in the BALANCE Model — effective January 1, 2026 — now cover semaglutide and other GLP-1 receptor agonists specifically for chronic weight management in patients with obesity or overweight with at least one weight-related condition, capping enrollee costs at $50 per month.
• Medicaid coverage of GLP-1 drugs for obesity has expanded to all 50 states under a separate federal directive — giving low-income Americans access to the same drugs that previously cost more per month than most Medicaid enrollees earn in a week.
• Most eligible beneficiaries have not yet accessed the benefit — surveys suggest fewer than 1 in 5 Medicare enrollees who qualify for GLP-1 obesity coverage are currently enrolled in a BALANCE Model plan, and many do not know the $50 cap exists.

What Changed — and Why It Took This Long

For most of Medicare’s history, weight-loss drugs were explicitly excluded from coverage. Congress wrote that exclusion into law when Medicare Part D was created in 2003. The reasoning reflected the medical consensus of the era — obesity was treated as a lifestyle issue, not a disease requiring pharmaceutical intervention, and weight-loss drugs at the time were modestly effective at best.

That consensus has collapsed. GLP-1 receptor agonists — a class of medications originally developed for type 2 diabetes management — turned out to produce weight loss outcomes that no prior obesity medication had come close to achieving. Clinical trials showed semaglutide, the active ingredient in both Ozempic and Wegovy, producing average weight reductions of 15% to 20% of body weight over 68 weeks. Tirzepatide, sold as Mounjaro for diabetes and Zepbound for obesity, produced even larger reductions in some trials.

The evidence base triggered a fundamental reclassification. In 2023, CMS determined that GLP-1 drugs used for weight management qualify as treatments for a disease — obesity — rather than lifestyle drugs, opening the door for Medicare coverage for the first time. The BALANCE Model, finalized in 2025 and effective January 1, 2026, is the implementation mechanism — a nationwide payment model that covers GLP-1 drugs for obesity in Medicare and Medicaid while simultaneously negotiating lower prices from manufacturers.

Who Qualifies — the Clinical Criteria

Not every Medicare or Medicaid enrollee with excess weight qualifies for covered GLP-1 treatment. The coverage criteria follow established clinical guidelines:

The BMI thresholds mean that a 5-foot-4-inch woman weighing 175 pounds or more — a BMI of approximately 30 — qualifies on the obesity criterion alone. At 27 BMI — approximately 157 pounds at the same height — qualifying requires also having hypertension, diabetes, sleep apnea, or another listed condition. For most Medicare beneficiaries managing chronic conditions alongside weight issues, the criteria are not difficult to meet. The barrier is awareness, not eligibility.

The Price Reality — Before and After Coverage

The cost of GLP-1 medications without insurance has been one of the most discussed healthcare affordability issues of the past three years. The numbers that drove that discussion have not changed materially:

The $50 cap applies to Medicare Part D enrollees in BALANCE Model participating plans after the drug’s negotiated price is applied. The $2,100 annual Part D out-of-pocket cap that also took effect January 1, 2026 provides an additional backstop — meaning even if a beneficiary’s GLP-1 costs exceed $50 in any given month, their total annual drug spending cannot exceed $2,100 regardless.

For a Medicare beneficiary who was previously paying full price for Wegovy — approximately $16,188 per year — the combination of BALANCE Model coverage and the Part D spending cap represents an annual savings of up to $13,988.

The Medicaid Expansion — Every State, Effective Now

Medicaid coverage of GLP-1 drugs for obesity is now required in all 50 states and Washington D.C. under a federal directive that took effect alongside the BALANCE Model. Previously, Medicaid coverage of weight-loss medications was a state-by-state patchwork — some states covered them, most did not.

The federal mandate changes that. States can no longer opt out of covering FDA-approved obesity medications for Medicaid enrollees who meet clinical criteria. The coverage applies to the same drug list as Medicare — semaglutide, tirzepatide, and other approved GLP-1 receptor agonists — with cost-sharing amounts that vary by state but are capped under Medicaid’s standard cost-sharing rules, which limit out-of-pocket costs for low-income beneficiaries to nominal amounts of $4 or less per prescription in most cases.

For the approximately 94 million Americans enrolled in Medicaid — disproportionately lower-income, often with higher rates of obesity-related conditions — this represents access to a class of medication that was effectively unavailable without insurance due to cost.

What the Hershey Earnings Call Just Confirmed

The expanding reach of GLP-1 drugs is already showing up in consumer spending data. Hershey’s most recent earnings call — released this week — confirmed the company has seen measurable shifts in snacking behavior that it attributes directly to increased GLP-1 adoption among American consumers. Hershey described benefiting from GLP-1 adoption in a counterintuitive way: as GLP-1 users eat less overall, they tend to spend more per purchase on higher-quality or more indulgent items rather than volume. But the underlying data point — that GLP-1 usage is now widespread enough to show up in a major food company’s quarterly results — is the clearest evidence yet that the drugs are reaching scale in the general population.

The Medicare and Medicaid coverage expansions are expected to accelerate that adoption significantly among older and lower-income Americans, the two populations historically least able to access the drugs due to cost.

Why Most Eligible Beneficiaries Have Not Yet Enrolled

The gap between eligibility and enrollment is the defining problem with the BALANCE Model in its first year. CMS estimates that up to 7 million Medicare beneficiaries currently meet the clinical criteria for covered GLP-1 obesity treatment. Surveys conducted by the Kaiser Family Foundation suggest fewer than 20% of those eligible are enrolled in a BALANCE Model participating plan and actively receiving the benefit.

Three barriers explain most of the gap. First, awareness: most Medicare beneficiaries have not been informed by their Part D plan or their physician that this coverage exists. The BALANCE Model was finalized with limited public communication, and CMS’s outreach to beneficiaries has lagged behind the program’s rollout. Second, plan participation: not every Part D plan participates in the BALANCE Model. Beneficiaries enrolled in non-participating plans cannot access the $50 cap without switching plans. Third, physician engagement: GLP-1 obesity prescriptions require a provider comfortable prescribing for obesity rather than just diabetes, and many primary care physicians have not yet updated their practice patterns to reflect the new coverage landscape.

Pro Tips a Generic Article Would Miss

1. If your current Part D plan does not participate in the BALANCE Model, you may have a Special Enrollment Period to switch — especially if you experienced a plan termination or coverage change at the start of 2026. The standard Medicare plan switching window closed March 31. But beneficiaries who had plans terminated, who moved, or who qualify under the new inaccurate directory Special Enrollment Period may still be able to change plans outside the standard window. Call 1-800-MEDICARE and specifically ask whether your situation qualifies for a Special Enrollment Period to access a BALANCE Model participating plan.

2. The $50 monthly cap under the BALANCE Model is separate from and in addition to the $2,100 annual Part D out-of-pocket cap. If your GLP-1 costs exceed $50 in any month, the additional amount you pay still counts toward the $2,100 annual cap. Once you hit $2,100 in total drug spending across all covered medications, your cost-sharing drops to zero for the rest of the year — including for your GLP-1 prescription. Beneficiaries managing multiple medications alongside a GLP-1 should track their cumulative Part D spending actively.

3. GLP-1 coverage under Medicaid requires a documented BMI and a clinical visit — not just a phone call. To access covered GLP-1 treatment under Medicaid, you need a face-to-face clinical encounter with a licensed provider who documents your BMI, diagnoses obesity or overweight-with-condition, and prescribes the medication. Telehealth prescriptions may qualify depending on your state’s rules. Contact your state Medicaid agency to confirm your state’s specific clinical documentation requirements before scheduling your appointment.

For any Medicare or Medicaid enrollee managing obesity alongside other chronic conditions — diabetes, hypertension, heart disease, sleep apnea — the first step is a conversation with a physician about whether a GLP-1 medication is clinically appropriate. If it is, the next step is verifying that your current Part D plan participates in the BALANCE Model and confirming your specific drug is on the plan’s formulary at the capped cost. Both verifications require a call to your plan’s member services line — not a website visit, because formulary databases are not always current. The coverage is real, the cost cap is real, and for the millions of eligible enrollees who have been priced out of these medications for years, so is the opportunity.

Frequently Asked Questions

Q: Does Medicare cover Ozempic and Wegovy for weight loss in 2026? A: Yes, for the first time. Medicare Part D plans participating in the BALANCE Model now cover GLP-1 medications including Ozempic and Wegovy for obesity treatment in eligible beneficiaries, with a $50 maximum monthly copay. Coverage requires meeting clinical criteria including a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.

Q: Does Medicaid cover Ozempic and Wegovy in 2026? A: Yes. A federal directive effective January 1, 2026 requires all 50 states and Washington D.C. to cover FDA-approved obesity medications including GLP-1 drugs for eligible Medicaid enrollees. Cost-sharing is capped at nominal amounts under Medicaid’s standard rules, typically $4 or less per prescription for most beneficiaries.

Q: How much does Wegovy cost under Medicare in 2026? A: Under the BALANCE Model, eligible Medicare Part D enrollees pay a maximum of $50 per month for covered GLP-1 medications including Wegovy. Without insurance, Wegovy costs approximately $1,349 per month — making the Medicare coverage cap a savings of up to $1,299 per month for eligible enrollees.

Q: Who qualifies for Medicare GLP-1 coverage for obesity? A: Medicare beneficiaries with a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related condition such as type 2 diabetes, hypertension, cardiovascular disease, obstructive sleep apnea, dyslipidemia, or osteoarthritis. A physician prescription and documentation of prior lifestyle intervention are also required.

Q: What if my Medicare plan doesn’t cover GLP-1 drugs for obesity? A: Not all Part D plans participate in the BALANCE Model. If your current plan does not offer the $50 cap for GLP-1 obesity coverage, you may need to switch plans during the next open enrollment period — October 15 to December 7, 2026 — for coverage effective January 1, 2027. Call 1-800-MEDICARE to identify BALANCE Model participating plans in your area.