In December 2025, the Centers for Medicare & Medicaid Services announced something that once seemed politically out of reach: a pathway to meaningful Medicare and Medicaid coverage for obesity medications. And now, the details of how CMS will make these important medicines available in Medicare are coming into focus.

The BALANCE Model

At the center of this shift is the BALANCE Model – short for Better Approaches to Lifestyle and Nutrition for Comprehensive Health – launched through the Center for Medicare & Medicaid Innovation.

For years, Medicare has largely excluded coverage for medications used to treat obesity as a primary diagnosis. That exclusion has stood in stark contrast to mounting evidence that obesity is a chronic, relapsing disease that drives cardiovascular disease, kidney failure, sleep apnea, and more. The BALANCE Model signals a reframing.

A Transition Starts in 2026

Before BALANCE begins in 2027, CMS will use a short-term Section 402 demonstration to provide transitional coverage in the second half of 2026. Then, starting January 1, 2027, BALANCE will allow eligible beneficiaries to access anti-obesity medications through participating Medicare Part D plans and, for states that opt in, Medicaid programs. Participation is voluntary for plans, states, and manufacturers.

Important Details

Notably, the model sets a defined monthly price for participating GLP-1–based therapies – including semaglutide, tirzepatide, and eventually orforglipron if approved – and pairs medication access with evidence-based lifestyle support. This pairing is important. Medication alone is not a comprehensive obesity strategy. But neither is lifestyle counseling alone sufficient for many people living with this disease.

Eligibility criteria, as reported, focus on individuals with obesity plus significant cardiometabolic risk – prior myocardial infarction or stroke, chronic kidney disease, heart failure, moderate to severe sleep apnea, or metabolic steatohepatitis. In other words, this is not framed as cosmetic weight loss coverage. It is targeted chronic disease management.

Open Questions

Still, critical questions remain. Because participation is voluntary, access will depend on which plans and states opt in. And beneficiaries who already qualify for GLP-1 coverage under other medically accepted indications will continue under existing pathways.

BALANCE is not a blank check. It is a structured experiment. But after decades of policy inertia, it represents a tangible acknowledgment that treating obesity as a disease – not a lifestyle choice – is long overdue.

Click here, here, and here for more perspective on the BALANCE Model. Many thanks to Cristy Gallagher and the Obesity Care Advocacy Network for assisting with research on this evolving subject.

Model of Tirzepatide and the GLP-1 Receptor, illustration by Fvasconcellos / Wikimedia Commons