For twenty years, Medicare Part D explicitly excluded weight loss medications—a policy rooted in the safety concerns of 1990s-era diet drugs and an outdated view of obesity as lifestyle choice rather than chronic disease. That's finally changing.
The BALANCE Act and associated CMS demonstration programs are creating pathways for Medicare beneficiaries to access GLP-1 medications. Here's what men over 65 need to know.
The Historical Exclusion
The Medicare Modernization Act of 2003 explicitly excluded "agents used for anorexia, weight loss, or weight gain" from Part D coverage. This was a direct response to the fen-phen heart valve crisis of the 1990s.
The exclusion persisted even as obesity medicine advanced dramatically. GLP-1 medications with robust safety profiles and proven cardiovascular benefits couldn't be covered solely for weight loss—regardless of clinical need.
The workaround: Medicare covers GLP-1s for diabetes (Ozempic, Mounjaro) and, after the SELECT trial, for cardiovascular risk reduction. But the weight loss indications of Wegovy and Zepbound remained excluded.
What's Changing: The BALANCE Model
CMS (Centers for Medicare & Medicaid Services) announced a demonstration program that will test Medicare coverage of anti-obesity medications. The model is named BALANCE—though the precise acronym meaning is bureaucratically generated.
Timeline:
- July 2026: Demonstration program launches in select markets
- January 2027: Full nationwide coverage expected if demonstration succeeds
Coverage parameters (expected):
- Copay capped at approximately $50/month
- Coverage for FDA-approved anti-obesity medications (Wegovy, Zepbound)
- BMI eligibility requirements aligning with FDA indications
- Likely requirement for concurrent nutrition/behavioral counseling
Why This Matters for Men Over 65
Older men face a particularly challenging intersection of obesity and age-related health decline:
Cardiovascular risk peaks: Men 65+ with obesity have dramatically elevated risk of heart attack, stroke, and heart failure. The SELECT trial showed 20% reduction in major cardiovascular events—this isn't cosmetic weight loss, it's mortality reduction.
Sarcopenic obesity: Aging naturally reduces muscle mass while obesity increases. The combination—sarcopenic obesity—creates metabolic dysfunction that's particularly difficult to address without pharmacological support.
Limited alternatives: Bariatric surgery becomes higher risk with age. Intensive lifestyle intervention requires mobility that many older adults don't have. GLP-1 medications fill a genuine therapeutic gap.
Fixed incomes: Medicare beneficiaries typically can't absorb $500-1,000/month medication costs that working-age patients might manage. Coverage is the difference between access and exclusion.
The SELECT Trial Changed Everything
The SELECT trial (Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity) fundamentally shifted the coverage conversation:
Key findings:
- 17,604 participants, average age 62
- 20% reduction in major adverse cardiovascular events
- Participants had established cardiovascular disease or high risk—but not diabetes
The regulatory impact: FDA approved Wegovy for cardiovascular risk reduction in March 2024—creating an indication that arguably bypasses the weight loss exclusion. Some Medicare Advantage plans have begun covering Wegovy under this indication.
The policy impact: SELECT demonstrated that anti-obesity medications reduce Medicare's biggest cost driver—cardiovascular events. The actuarial case for coverage became compelling.
Current Options While Waiting
If you're on Medicare and can't wait for BALANCE implementation:
Option 1: Cardiovascular indication
If you have established cardiovascular disease or multiple risk factors, ask your physician about Wegovy for cardiovascular risk reduction rather than weight loss. Some Medicare Advantage plans are covering this indication now.
Option 2: Diabetes indication
If you have type 2 diabetes, Mounjaro and Ozempic are covered for glycemic control. The weight loss benefit comes along with the diabetes treatment.
Option 3: Cash pay with savings programs
Manufacturer savings programs typically exclude Medicare beneficiaries. However, LillyDirect and some manufacturer programs may have pathways. Check current eligibility.
Option 4: State pharmaceutical assistance programs
Some states offer supplementary drug coverage for Medicare beneficiaries. Check your state's program for potential coverage.
What to Expect with BALANCE Coverage
Based on demonstration program details and legislative proposals:
Eligibility likely requirements:
- BMI ≥30, or BMI ≥27 with weight-related comorbidity
- Primary care provider authorization
- Possible requirement for documented lifestyle intervention attempt
- Possible requirement for concurrent nutrition counseling
Cost sharing:
- Monthly copay expected around $50
- No deductible for covered medications in many proposed models
- Annual out-of-pocket cap applies
Covered medications:
- Wegovy (semaglutide 2.4mg) likely covered
- Zepbound (tirzepatide) likely covered
- Oral Wegovy likely covered when available
- Generic liraglutide (Saxenda) likely covered
Preparing for Coverage
Steps to take now:
- Document your weight history: Keep records of BMI measurements, prior weight loss attempts, and related health conditions.
- Establish care: Have an ongoing relationship with a primary care provider who can prescribe when coverage becomes available.
- Address comorbidities: Document sleep apnea, hypertension, prediabetes, or other weight-related conditions that strengthen coverage eligibility.
- Review your Medicare plan: Some Medicare Advantage plans may offer enhanced coverage before traditional Medicare. Compare options during enrollment periods.
- Monitor announcements: CMS will announce specific implementation details as the July 2026 launch approaches.
The Bigger Picture
Medicare covering anti-obesity medications represents a fundamental shift in how the healthcare system views obesity—from personal failing to chronic disease requiring medical treatment.
For men over 65, this shift is particularly meaningful. The generation that grew up being told to "just eat less and exercise more" finally has access to tools that actually work. The SELECT trial proved these medications save lives, not just reduce waistlines.
The $50 copay target makes GLP-1s accessible on fixed incomes. The coverage framework validates seeking treatment. And the cardiovascular benefits mean this isn't vanity—it's preventive care that reduces the strokes and heart attacks that devastate older men's health.
July 2026 isn't far away. Start preparing now.