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By The RX Index Editorial TeamLast verified: May 28, 2026Sources: CMS, KFF, AHA — re-checked monthly

Why Was the CMS BALANCE Model Delayed?

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Short answer

Not enough insurers signed up. The Medicare side of the model needed health plans covering at least 80% of Part D enrollment to opt in by April 20, 2026. They didn’t. So on April 21, 2026, CMS hit pause on the Medicare launch and said it wanted more real-world data before trying again.

Here’s the part the scary headlines skip: the delay did not take away the $50-a-month GLP-1 deal. The program behind that price — the Medicare GLP-1 Bridge — didn’t shrink. It got bigger. It’s now scheduled to start July 1, 2026 and run through December 31, 2027. The Medicaid side of BALANCE is still moving forward too.

This page is for Medicare and Medicaid members, caregivers, and the doctors trying to keep it all straight. It is not medical advice — that’s between you and your prescriber. What we’ll do is untangle four programs that sound almost identical, tell you plainly what changed, why it changed, and exactly which door is yours now.

The RX Index is a pricing intelligence and comparison resource for GLP-1 telehealth providers. Some links on this page are partner links, and we may earn a commission if you start care through one — at no extra cost to you. It never changes our reporting on CMS policy, which comes straight from the official sources listed at the bottom.

Check my GLP-1 path →

Free 60-second quiz. No sign-up, no provider pitch — just your clearest next step.

The CMS BALANCE delay, in one table

The April 2026 delay only paused the Medicare Part D part of the BALANCE Model. The Medicaid part is still going forward state by state, and the separate Medicare GLP-1 Bridge ($50/month) was extended through the end of 2027. “BALANCE is canceled” is not accurate — the part most people actually need is still on the way.

Coverage path	What people expected	Where it stands now	Why it changed / why it matters	What to do
Medicare Part D BALANCE	Built-in obesity coverage through Part D plans, 2027–2031	⏸ Delayed. Not launching in 2027. Possibly later.	Too few insurers opted in (the 80% rule, below). CMS wants more data first.	Don’t pick a 2027 plan assuming BALANCE exists. Use the Bridge or standard Part D instead.
Medicare GLP-1 Bridge	A short 6-month bridge (July–Dec 2026)	✅ Scheduled for July 1, 2026 and extended through Dec 31, 2027	This is the workaround. It asks insurers for nothing, so it survived. $50/month flat.	If you’re on Part D and want coverage for weight loss, check the Bridge criteria.
Medicaid BALANCE	States could opt in starting 2026	✅ Still moving forward, state by state	The delay was Medicare-only. Medicaid was never paused.	Check your state Medicaid program — not your Medicare plan.
Standard Part D	Normal drug coverage for already-covered uses	✅ Unchanged	GLP-1s for diabetes, heart-risk, or sleep apnea were never tied to BALANCE.	Ask your plan about your exact drug and diagnosis.

Sources: KFF; CMS Innovation Center; CMS Medicare GLP-1 Bridge FAQ; AHA. Last verified May 28, 2026.

The takeaway in one line: one program got paused, two are still on, and the cheapest near-term path ($50/month) is bigger than it was.

What is the CMS BALANCE Model, exactly?

The BALANCE Model — short for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth — is a voluntary CMS test program, announced in December 2025, designed to expand Medicare and Medicaid coverage of GLP-1 weight-loss drugs in exchange for negotiated prices and standard coverage rules.

The reason BALANCE exists at all comes down to an old rule most people have never heard of: Medicare is banned by law from covering medicine used only for weight loss. It can cover a GLP-1 for diabetes or heart disease. Not for obesity by itself. Medicaid can cover weight-loss drugs, but it’s optional — and as of January 2026, only 13 states did, down from 16 the year before, mostly because of cost.

BALANCE was the government’s attempt to work around that ban. Drugmakers Eli Lilly and Novo Nordisk both agreed to join and to hand over their GLP-1s at a lower negotiated price. In return, they’d reach far more Medicare and Medicaid customers.

BALANCE was never “permanent” coverage. It’s a time-limited model — a five-year test, 2027 through 2031 — meant to be the bigger, longer-term solution while the rules got worked out. What got delayed was its Medicare half. Not the whole idea, and not the part already lined up to help people this summer.

For the full BALANCE eligibility breakdown: CMS BALANCE Model GLP-1 guide →

Why was the CMS BALANCE Model delayed?

The Medicare Part D portion of BALANCE was delayed because CMS did not get enough health plans to join. The model would only launch if Part D plan sponsors covering at least 80% of Part D enrollment applied by April 20, 2026, and that bar was not met. CMS announced the pause on April 21, 2026 and said the extra time would let it collect more data on how the drugs are actually used.

That’s the official reason. But “why” has a few layers, and you deserve all of them.

The model was voluntary — and insurers had to choose to play.

BALANCE didn’t force any plan to cover GLP-1s. Plans had to apply through an official sign-up document (CMS calls it a Request for Applications). If too few applied, the whole Medicare launch was off.

CMS set an 80% bar to stop “adverse selection.”

Adverse selection is simple: if only some plans cover an expensive drug, the people who need it rush into those plans, and costs pile up on a handful of insurers. To prevent that, CMS said BALANCE would only start if plans covering 80% of Part D enrollment opted in. Plans had to apply by April 20, 2026. The bar wasn’t met.

Insurers were scared of an open-ended bill.

GLP-1s aren’t a one-time cost. A huge share of members could want them, for years. Plans told CMS they couldn’t predict how many people would use the drugs — which means they couldn’t predict the cost. One consulting firm, Optum Advisory, said most plan sponsors didn’t even believe the 80% bar would be hit — yet many applied anyway, just so they wouldn’t be left out if it was.

The timing was terrible for Part D.

2027 plans were being designed in the middle of a major Medicare drug-benefit overhaul (new out-of-pocket caps, new payment rules). Adding a brand-new, pricey drug class on top of that — without CMS sharing the financial risk — looked to many plans like a money-loser that would push members’ premiums up.

The biggest players said “not yet.”

UnitedHealthcare and Aetna (part of CVS) did not commit to BALANCE. UnitedHealthcare’s government-programs chief, Bobby Hunter, said the company wanted to find a “path to yes” — but flagged real concerns with how the model was built. To hit 80%, nearly all the giants had to say yes with conviction. Enough of them hesitated.

The complete, honest answer:

A voluntary program didn’t get enough volunteers, because insurers weren’t willing to take on an unpredictable cost during a chaotic year for Part D — and CMS chose to pause and study rather than launch something half-empty. The official who built it, CMS Innovation Center Director Abe Sutton, still believes in the model and framed it as a way to expand access to drugs that fight diabetes, heart disease, and other conditions. The will is there. The plan participation, for now, isn’t.

Was the BALANCE Model canceled, or just delayed?

It was delayed, not canceled. Only the Medicare Part D launch was paused; CMS has not said the entire BALANCE concept is dead. The Medicaid portion continues, the Medicare GLP-1 Bridge was extended through 2027, and CMS left the door open to launching BALANCE in Part D in a future year.

This distinction matters because the words get mixed up everywhere — in news headlines, in Facebook groups, even in some plan call centers. We’ve watched people convince each other that “Medicare canceled GLP-1 coverage.” That’s wrong, and it scares people out of help they qualify for.

⏸ Paused

BALANCE in Medicare Part D. This is the part that hit the 80% wall.

✅ Still on

BALANCE in Medicaid (more on that below).

✅ Extended

The Medicare GLP-1 Bridge — stretched from a 6-month program to an 18-month one.

✅ Untouched

Standard Part D coverage for GLP-1s used for diabetes, heart-risk reduction, or sleep apnea.

If you remember one thing: the most useful program for everyday people — the $50 Bridge — didn’t go away. It grew.

What happens to the Medicare GLP-1 Bridge now?

The Medicare GLP-1 Bridge is now the main near-term path to GLP-1 weight-loss coverage on Medicare. It is scheduled to run from July 1, 2026 through December 31, 2027, charges eligible Part D members a flat $50 per month, and works outside the normal Part D system so insurers carry no risk for it. CMS extended it specifically to fill the gap left by the BALANCE delay.

It started as a stopgap and became the main event.

The Bridge was built as a six-month warm-up (July to December 2026) before BALANCE took over in 2027. When BALANCE stalled, CMS extended the Bridge to 18 months. So today we have an 18-month program with no confirmed permanent successor — a real point we’ll come back to.

Here’s the money math.

Lilly and Novo agreed to supply the covered drugs at a net price of $245 per month — that’s what the government pays. You, if eligible, pay a flat $50 copay per month. That $50 doesn’t rise as your dose goes up, and it doesn’t change based on where you are in your Part D year. For drugs that otherwise run hundreds of dollars a month with discounts — and well over $1,000 at full retail — that’s a massive difference.

It runs on a side track, not through your plan.

CMS hired a single company — Humana, which already runs a similar low-income drug program for Medicare — to manage approvals, claims, and pharmacy payments as the central processor. Your own Part D plan doesn’t have to opt in, and it pays nothing toward it. That’s exactly why the Bridge survived: it doesn’t need insurer buy-in.

Who actually qualifies: the three eligibility tiers

To qualify for the Bridge, you must be 18 or older and meet one of three criteria measured at the time you started GLP-1 therapy: a BMI of 35 or higher on its own; a BMI of 30 or higher with one qualifying heart or kidney condition; or a BMI of 27 or higher with prediabetes or a specific cardiovascular event in your history. Your prescriber must attest that you meet one of these, and the medication must be paired with structured nutrition and activity guidance.

BMI is a number that compares your weight to your height. Here’s how the three tiers work — you only need to meet one.

Tier	BMI (when you started the drug)	Plus one of these conditions
1	BMI 35 or higher	None needed
2	BMI 30 or higher	Heart failure with preserved ejection fraction (a type of heart failure where the heart pumps normally but doesn’t relax well), uncontrolled high blood pressure, or chronic kidney disease stage 3a or higher
3	BMI 27 or higher	Prediabetes, a previous heart attack, a previous stroke, or symptomatic peripheral artery disease (poor blood flow in the limbs that causes pain)

·This is stricter in the middle than people assume. If your BMI is 27 to 34, you need one of the specific conditions listed — not just “a heart condition” in general. But if your BMI is 35 or higher, you don’t need any extra diagnosis at all.

·The medication has to come with lifestyle support. CMS requires the drug to be paired with structured nutrition and physical-activity guidance, in line with the FDA-approved label.

·It’s only for weight loss. If your GLP-1 is prescribed for a condition Part D already covers, you use standard Part D instead.

Because the Bridge is the real next step for most readers, we keep a separate, fully updated guide just for it — with the exact prior authorization steps, the documents your provider needs, and what to do on day one.

See if you qualify for the Medicare GLP-1 Bridge →

What if you already take Wegovy, Zepbound, or Foundayo?

If you started a GLP-1 before July 1, 2026 — even before you were on Medicare — you may still qualify for the Bridge. CMS judges the BMI requirement at the time you started therapy, not the day you apply. That doesn’t approve you automatically, but it means the weight you’ve already lost on the drug won’t disqualify you on the BMI test.

Say you started Zepbound in 2024 at a BMI of 37, and it worked — you’re down to a BMI of 34 today. Do you lose access?

On the BMI part of the test, no. Your prescriber attests that you met the BMI 35 threshold when therapy began. CMS gives this exact example and confirms it counts. The same goes for people who started a GLP-1 before they aged into Medicare.

The honest caveat: meeting the BMI rule is one piece. You still need to be enrolled in Part D, meet the full tier criteria, and have your provider submit the attestation. So it’s not an automatic yes — but the progress you’ve made is not held against you.

What’s the catch with the Bridge? (the honest part)

The Bridge has three real downsides: the $50 copay does not count toward your Part D deductible or your yearly out-of-pocket cap, low- income subsidies (Extra Help) do not lower the $50, and the program ends December 31, 2027. For most people paying full cash today it’s still a great deal, but it’s not perfect and it’s not permanent.

⚠️ The $50 doesn’t count toward your out-of-pocket protections.

In a normal year, what you spend on drugs counts toward your Part D out-of-pocket cap — $2,100 in 2026, rising to $2,400 in 2027 — and once you hit it, your covered drugs are basically free for the rest of the year. The Bridge runs on its side track, so its costs don’t count toward that cap or your deductible. You’ll pay $50 every month, all year.

⚠️ Extra Help (Low-Income Subsidy) does not apply.

If you get Extra Help (the program that slashes drug costs for lower-income people), it does not apply to the Bridge. So a beneficiary who pays $0–$10 for their other medicines still pays the full $50 here. For someone on a tight fixed income, $50 a month can be a real barrier.

⚠️ The program ends December 31, 2027.

There’s no confirmed permanent program after the Bridge ends. We’ll update this page when CMS announces one. Plan for what comes after.

For people facing full retail prices near $1,000 a month or more with no help at all, a flat $50 that never rises with your dose and never jumps around as you move through your plan year is life-changing. The Bridge skips the normal Part D machinery — and that’s exactly what lets it offer one simple, predictable price. Just go in knowing the cap rule, the Extra Help gap, and the 2027 expiration date.

If the cap or Extra Help limit is your issue, switch lanes: ask your plan whether your GLP-1 can be covered under standard Part D for a condition you already have (diabetes, heart-risk, sleep apnea), or check whether your state Medicaid covers GLP-1s. Those paths can use your normal low-income protections.

Deep-dive: True out-of-pocket costs on the Medicare GLP-1 Bridge → · Bridge and the Part D coverage gap →

Which GLP-1 drugs does the Bridge actually cover?

The Medicare GLP-1 Bridge covers selected FDA-approved weight-loss medications: Wegovy injection, Wegovy tablets, the Zepbound KwikPen, and Foundayo (orforglipron, an FDA-approved oral GLP-1 pill for weight loss). It does not cover Zepbound vials or single-dose pens, and it does not cover Ozempic or Mounjaro for weight loss.

Drug	In the Bridge?	The fine print
Wegovy (injection)	✅ Yes	For weight management.
Wegovy (oral tablets)	✅ Yes	The pill form is included too.
Zepbound KwikPen	✅ Yes	Only the KwikPen.
Foundayo (orforglipron)	✅ Yes	An FDA-approved oral GLP-1 pill for weight loss.
Zepbound (vial / single-dose pen)	❌ No	These forms aren’t on the Bridge list.
Ozempic / Mounjaro / Rybelsus	❌ Not for weight loss	May be covered by standard Part D for diabetes — a different door.

One compliance point we won’t blur: the Bridge and BALANCE cover specific, FDA-approved brand-name medications only. Compounded GLP-1s (versions mixed by a pharmacy rather than made by the brand manufacturer) are not part of these programs and are not a substitute for them. Anyone telling you otherwise is wrong.

Bridge drug list vs. BALANCE drug list: why are they different?

The Bridge covers a short weight-loss list (Wegovy injection and tablets, the Zepbound KwikPen, and Foundayo). The broader BALANCE Model would have covered more — all formulations of Foundayo, Mounjaro, Ozempic, Rybelsus, and Wegovy, plus the Zepbound KwikPen. That’s why you’ll see Ozempic and Mounjaro in BALANCE materials but not on the Bridge’s weight-loss list.

Program	Drugs it covers
Medicare GLP-1 Bridge (weight loss)	Wegovy injection, Wegovy tablets, Zepbound KwikPen, Foundayo
BALANCE Model (if it launches)	All formulations of Foundayo, Mounjaro, Ozempic, Rybelsus, and Wegovy, plus the Zepbound KwikPen

The simple way to hold it: the Bridge is the smaller, faster program for weight loss specifically. BALANCE was meant to be the wider one. And remember — drugs like Ozempic and Mounjaro can still be covered today through standard Part D when they’re prescribed for diabetes.

Did CMS delay Medicaid BALANCE too?

No. The delay applied only to the Medicare Part D portion. The Medicaid side of BALANCE is still moving forward as a voluntary, state-by-state program. CMS is accepting applications from state Medicaid agencies through July 31, 2026, and states can begin between May 1, 2026 and January 1, 2027.

This is the single most misread part of the whole story. The Medicare pause and the Medicaid program are separate. KFF confirms the Medicare delay does not affect Medicaid.

✓Your answer depends entirely on your state. A national CMS announcement doesn’t automatically mean your state joined.

✓Watch your state, not your Medicare plan. Look for your state Medicaid program’s pharmacy bulletins and announcements.

✓The window is rolling. States that join after January 1, 2027 can only do so if CMS allows it.

If you have both Medicare and Medicaid (dual-eligible), don’t assume Medicaid is your only option — you may be able to use the Bridge instead, if you meet its rules. When you’re not sure, the path checker sorts it for you.

Bridge vs. BALANCE vs. standard Part D: which one is yours?

The right path depends on your insurance type, your drug, and crucially — why the drug is prescribed. The Bridge is for weight-loss use by eligible Part D members. Standard Part D is the route for GLP-1s prescribed for conditions it already covers, like diabetes, heart-risk reduction, or sleep apnea. Medicaid BALANCE depends on your state opting in.

One rule prevents most mistakes: if your GLP-1 is for a condition Part D already covers, you can’t use the Bridge for it — even if your specific plan doesn’t have it on its list. The Bridge is strictly for weight loss.

Your situation	Your likely path	First move
Part D + Bridge-covered drug + for weight loss + meets a tier	Medicare GLP-1 Bridge	Ask your prescriber to submit a Bridge prior authorization.
Part D + Wegovy for heart-risk reduction	Standard Part D	Use your plan’s formulary/approval process.
Part D + Zepbound for sleep apnea	Standard Part D	Use your plan’s formulary/approval process.
Part D + Ozempic/Mounjaro for diabetes	Standard Part D	Use your plan’s formulary/approval process.
Medicaid only	Medicaid BALANCE, if your state joined	Check your state Medicaid GLP-1 policy.
Both Medicare + Medicaid (dual)	Possibly the Bridge, possibly Medicaid	Run the path checker — it depends on plan and state.
No qualifying CMS route	Cash-pay or commercial insurance	Rule out CMS coverage first, then compare options.

Find my exact path in 60 seconds →

Answer a few quick questions and get a plain-English next step.

Who does the BALANCE delay actually hurt — and who’s fine?

The delay is a real setback for one group: Medicare members who wanted permanent, built-in Part D coverage of GLP-1s for obesity starting in 2027. For almost everyone else — Bridge-eligible members, Medicaid enrollees in participating states, and anyone using a GLP-1 for diabetes, heart disease, or sleep apnea — the delay changes little or nothing.

Genuinely a setback if you are…

A Part D member who wanted lasting, dose-flexible obesity coverage baked into your plan, with costs that count toward your out-of-pocket cap. BALANCE was meant to grow into that. For now it’s deferred, and you’re leaning on a program that ends in 2027.

Barely affects you if you are…

✓Bridge-eligible. Still on track for $50/month from July 2026, now for a full extra year.
✓On Medicaid in a state that’s joining. Your path is on track.
✓Using a GLP-1 for diabetes, heart-risk, or sleep apnea. Your coverage runs through standard Part D and was never part of BALANCE.

In a gap if you are…

Not enrolled in Part D, don’t meet a Bridge tier, in a Medicaid state that opts out, or you need a drug form the Bridge doesn’t cover. That’s the group most likely to look at cash-pay options while the policy settles.

Will the BALANCE Model ever launch in Medicare?

Maybe, but it’s not guaranteed. CMS called the Part D pause indefinite and tied any future launch to collecting more usage data and getting more insurers comfortable. A relaunch could come in a later year, but CMS has not promised a date, and there is no confirmed permanent program after the Bridge ends in December 2027.

BALANCE comes back to Medicare only if two things change at once: CMS produces enough data to make the cost predictable for plans, and the model gets reworked so insurers carry less risk. Until then, the Bridge is the placeholder — and it has a hard expiration.

The 2027 date is the real clock to watch. If neither BALANCE returns nor the Bridge gets extended again, Medicare’s weight-loss coverage could narrow at the end of 2027. KFF also flags quieter risks even if BALANCE does launch later: plans could drop out before the model’s final year, interrupting treatment, and it’s unclear whether plans could keep covering obesity GLP-1s once the model ends unless Congress lifts the original ban. We’ll keep this page current as CMS releases more. For now: don’t wait for 2027. Use what’s real today.

Full detail on what comes after: What happens after the Medicare GLP-1 Bridge ends →

What should you do before July 1, 2026?

Don’t wait for BALANCE in 2027. Confirm your Part D plan type, figure out whether your prescription is for weight loss or an already-covered condition, gather your BMI and diagnosis records, and talk to your prescriber about the Bridge before it launches on July 1, 2026.

Bring these to your doctor:

✓Your Medicare card and Part D / Medicare Advantage card
✓Your current medication list
✓The medication you want
✓Your diagnosis (and whether it’s for weight loss or another condition)
✓Your BMI when you started the GLP-1 (or your current BMI if you’re starting now)
✓Records of any qualifying conditions
✓Any past approval or denial letters from your plan

Ask Your prescriber:

“Based on my BMI when I started therapy, my diagnoses, and my Part D plan type, do I appear to meet one of the Medicare GLP-1 Bridge tiers?”

Ask Your plan:

“Is my GLP-1 being handled under standard Part D for a covered condition, or should my prescriber submit it through the Medicare GLP-1 Bridge central processor?”

Those two sentences put you ahead of most people walking into July 1 confused.

What if you don’t qualify for the Bridge or Medicaid BALANCE?

If no CMS route fits, first double-check whether standard Part D covers your GLP-1 for a condition you already have. If it truly doesn’t, your remaining options are commercial insurance or an FDA-approved cash-pay route through a telehealth provider — with your prescriber’s guidance. A cash-pay provider is a backup, not a replacement for Medicare coverage.

Re-check standard Part D.

A surprising number of people qualify here without realizing it, because their GLP-1 use lines up with diabetes, heart-risk reduction, or sleep apnea. That path can use your normal cost protections. Exhaust it first.

If you’re truly outside every CMS route, compare cash-pay FDA-approved options.

One mainstream choice is Ro Body (sponsored affiliate link, opens in a new tab), which carries FDA-approved options including Wegovy (pill and pen), Foundayo, and Zepbound. Two things to know up front: Ro can’t coordinate coverage for government plans (Medicare, most Medicare Advantage, Medicaid, VA, or TRICARE). If you’re on Medicare you can still join and pay cash; if you’re on Medicaid, Ro currently isn’t available to you at all. The Ro Body membership (sponsored affiliate link, opens in a new tab) is reported at $39 for the first month, then as low as $74/month with annual prepay — and the GLP-1 itself is billed on top of that. Verify current pricing before relying on it.

To be crystal clear: this is not the Medicare $50 Bridge. It’s a self-pay path for people who don’t qualify for a government route and choose to pay out of pocket.

Self-pay FDA-approved GLP-1s (not the Medicare Bridge)

Affiliate link. For readers who have confirmed no CMS route fits and want to compare cash-pay brand options.

See Ro’s cash-pay FDA-approved options →

Cash-pay price comparison: GLP-1 cost without insurance: full guide → · Medicare GLP-1 Bridge MFP: $50 vs 2027 prices →

How we verified this

This page is built from primary and authoritative sources — CMS’s own Innovation Center pages, the CMS Medicare GLP-1 Bridge FAQ, the CMS Part D BALANCE Request for Applications, and KFF’s policy brief — backed by reporting from AHA, NPR, and the healthcare trade press, plus Ro’s own published pages for the cash-pay details. We separate official facts from our own analysis and date every figure.

Facts we treated as confirmed, and where they come from:

✓The Medicare Part D launch was delayed (announced April 21, 2026); the 80% participation bar wasn’t met — CMS RFA and KFF.
✓The Bridge is scheduled for July 1, 2026 – Dec 31, 2027 at a flat $50 copay; $245 manufacturer net price — CMS Bridge FAQ and KFF.
✓The $50 doesn’t count toward the out-of-pocket cap, and Extra Help/LIS doesn’t reduce it — CMS Bridge FAQ, KFF, NPR.
✓The three eligibility tiers (BMI 35; BMI 30 + condition; BMI 27 + condition), judged at therapy start — CMS Bridge FAQ.
✓Bridge drugs: Wegovy injection and tablets, Zepbound KwikPen, Foundayo; vials/single-dose pens excluded — CMS Bridge FAQ.
✓Humana is the central processor — CMS guidance and reporting.
✓Medicaid BALANCE is proceeding; state applications through July 31, 2026 — AHA and KFF.
✓Ro is cash-pay for government-plan members, can’t coordinate government coverage except FEHB, can’t serve Medicaid, and prices medication separately — Ro’s own insurance and pricing pages.

What’s our judgment, not fact: who the delay helps vs. hurts, and “check the Bridge first.” That’s analysis based on the verified facts above — not medical or legal advice. CMS, KFF, and AHA figures are sourced and dated; Ro pricing and any provider-specific details should be reverified before you rely on them.

Last verified: May 28, 2026. We re-check this page monthly through the end of 2026, and immediately if CMS changes the Bridge, the drug list, the copay, or the BALANCE status.

Frequently asked questions

Was the BALANCE Model canceled?

No. Only the Medicare Part D portion was delayed (announced April 21, 2026). The Medicaid portion is still going forward, and the Medicare GLP-1 Bridge was extended through December 2027.

Why was the CMS BALANCE Model delayed?

Not enough insurers signed up. The model needed Part D plans covering at least 80% of Part D enrollment to apply by April 20, 2026. That bar wasn’t met, so CMS paused the Medicare launch to gather more data.

Did the Medicare GLP-1 Bridge get delayed too?

No — the opposite. The Bridge was extended. It’s now scheduled to run July 1, 2026 through December 31, 2027.

Does Medicare cover Wegovy or Zepbound for weight loss?

Starting July 1, 2026, yes — for eligible Part D members through the GLP-1 Bridge ($50/month). It covers Wegovy (injection and pill), the Zepbound KwikPen, and Foundayo. For diabetes, heart-risk, or sleep apnea, standard Part D may cover them.

Who qualifies for the Bridge?

You must be on a Medicare Part D plan and, at the time you started the drug, meet one of three tiers: BMI 35+; BMI 30+ with heart failure with preserved ejection fraction, uncontrolled high blood pressure, or chronic kidney disease stage 3a+; or BMI 27+ with prediabetes, a prior heart attack, a prior stroke, or symptomatic peripheral artery disease.

Does the $50 Bridge copay count toward my out-of-pocket cap?

No. The Bridge works outside normal Part D, so the $50 doesn’t count toward your deductible or your yearly out-of-pocket cap ($2,100 in 2026, $2,400 in 2027). Extra Help also doesn’t lower it.

Does the Bridge cover Ozempic or Mounjaro for weight loss?

No. The Bridge weight-loss list is Wegovy, the Zepbound KwikPen, and Foundayo. Ozempic and Mounjaro may be covered by standard Part D for diabetes.

Does the delay affect Medicaid?

No. The Medicare delay didn’t stop Medicaid BALANCE. State Medicaid agencies can still apply through July 31, 2026, but whether you benefit depends on your state joining.

Should I wait for BALANCE in 2027?

No. It isn’t launching in 2027. If you’re on Medicare and want coverage now, check the Bridge or standard Part D depending on your diagnosis.

I already take a GLP-1. Will I still qualify?

Possibly. The Bridge judges the BMI requirement at the time you started therapy, so weight you’ve already lost won’t disqualify you on that test — but you still need to meet the full criteria and be enrolled in Part D.

What happens after December 31, 2027?

That’s still uncertain. CMS hasn’t confirmed a permanent program after the Bridge ends. We’ll update this page as soon as it does.

Are compounded GLP-1s part of BALANCE or the Bridge?

No. Both programs cover specific FDA-approved brand-name drugs only. Compounded GLP-1s are not included and are not a substitute.

Still not sure which GLP-1 program is right for you?

Take our free 60-second matching quiz. No sign-up, no provider pitch — we’ll just tell you whether your likely next step is the Bridge, Medicaid, standard Part D, or a backup route.

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Related guides

Sources

By The RX Index Editorial Team — a pricing intelligence and comparison resource for GLP-1 telehealth providers. Published May 28, 2026. Last verified: May 28, 2026. This page is for coverage research and decision support. It is not medical, legal, or financial advice, and it is not a substitute for your prescriber, your Medicare plan, your state Medicaid agency, or your pharmacist. Some links are affiliate links — we may earn a commission at no extra cost to you. It never affects our coverage reporting.