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If you're on Medicare or you love someone who is and you've been waiting for GLP-1 coverage, what happened in Washington this week matters to you. This morning is Thursday, April 23rd, 2026, and this is what I know as of today. Over the last 72 hours, the plan to give seniors access to GLP-1s has hit a wall. Two of the biggest insurance companies in the country said they would not participate. And in an email sent to Part D plan sponsors on Tuesday afternoon, CMS confirmed they are pulling back the long-term program called balance and extending the short-term one called the Medicare GLP-1 bridge through the end of 2027. I'm going to walk you through what happened, what it means if you're trying to get care, and what we still do not know.
Hello everyone, my name is Christopher Durham. My wife Lorraine and I host this channel. We like to call it The Down Sas. We are simply an average suburban couple from North Carolina, married 23 years with three kids. Together we've lost more than 150 lbs using GLP-1s, and we've paid out of pocket the entire way. We cover this industry from the patient perspective because that's who we are, patients. We read the trial data, the earnings calls, and the policy documents, and we translate what's happening into language you can hopefully understand, which brings me to today.
Before we get into it, the usual reminder, nothing in this video is medical advice. Nothing in this video is financial advice. If you are considering GLP-1s or if you are thinking about changing your treatment, talk to your doctor. If you are navigating Medicare coverage decisions, talk to a licensed Medicare advisor. This is a video about what is happening in the changing landscape. It is not a substitute for professional guidance on your specific situation. And if you find this kind of video useful, please take a second to like this video and subscribe to the channel. We cover GLP-1 news, policy, research, and patient stories every week. Subscribing is how you make sure you do not miss the next update on a story like this one because as you're about to see, these stories move very fast.
Here's the basic picture. Medicare has not covered GLP-1s for weight loss since the 1990s. There's a federal law that generally prevents Medicare from paying for weight loss drugs, which is why a senior with obesity has not been able to get Wegovy or Zepbound covered even if their doctor prescribes it. If you had Medicare and you wanted one of these medications, you were paying cash, full retail, out of pocket. Late last year, the administration announced a plan to change that. The plan has two parts, and it is important to understand both because they are not the same thing.
The first part is the Medicare GLP-1 bridge. The bridge is a short-term federal program run directly by the federal government. Starting July 1st, 2026, if you are a Medicare beneficiary who meets the clinical criteria, you can get Wegovy or Zepbound for $50 a month. CMS has confirmed how this is going to run. Humana will serve as the central processor. CMS chose Humana because they already administer a program called limited income newly eligible transition or LEANET, which is the federal safety net that covers low-income Medicare beneficiaries during gaps in their drug coverage. CMS is using that existing infrastructure because it has the national scale and the operational capability to handle broad access starting July 1st. In practical terms, that means your doctor submits a prior authorization request to Humana, not to your Part D plan. Humana handles the approval, the claims, and the payment to the pharmacy. If you qualify, you pay $50 at the pharmacy counter. It does not matter which Part D plan you're on. The bridge works the same way for everyone who qualifies. There's a lot more detail I'm not going to go into today on exactly who qualifies, which medications are covered, and how the program actually runs. We put out a full explainer video on the bridge earlier, and it walks through everything we know as of today. Link in the description below. If you want the deep dive, go there. For this video, I'm focused on the news this week.
Now, the second part is the balance model. That is the longer-term plan. Balance was supposed to take over from bridge on January 1st, 2027, and move the coverage into regular Medicare Part D plans. The federal government negotiated prices with the drug companies, and then Part D plans, which are run companies like United Healthcare, Humana, CVS, and others, were supposed to voluntarily sign up to offer that coverage to their members. The keyword there is voluntary. Insurance companies were not required to participate. They had to choose to. Think of it this way. CMS said they needed insurance companies covering at least 80% of Medicare drug plan members to agree to participate. If most insurers said no, the program would not launch because there would not be enough coverage to make it work. That threshold was the test of whether the industry was on board. And that's where this news comes in.
Based on industry insiders and conversation with CMS, the picture heading into this week, as I talked about in the video last week, was that the 80% threshold appeared to have been met. That was the read at the time. It turned out to be optimistic. On Monday, April 20th, insurance companies had to formally tell the federal government whether they were in. CVS told Bloomberg it has declined to participate in the program to cover GLP-1 weight loss drugs under Medicare. United Health, the largest Medicare Advantage provider in the country, would not commit either. On their earnings call Tuesday morning, Bobby Hunter, who runs their government program, said there are, quote, "notable challenges and outstanding questions with the currently planned structure." He said they are still working through the process internally. That's not a yes.
So, let me spend a minute or two on CVS because their decision to sit this out matters more than a single headline suggests. To understand why CVS saying no is such a big deal, you need to understand that CVS is three companies in one, and each piece touches a different part of your prescription. The first is Aetna, CVS Health's insurance company. They cover roughly 25 to 26 million medical members across commercial, Medicare, and Medicaid plans with about 3.3 to 3.5 million of those in Medicare Advantage. So, when CVS Health says no to balance, they are making that decision on behalf of the millions of seniors in Aetna Medicare Advantage plans who might have been hoping for GLP-1 coverage.
The second is CVS Caremark, one of the three largest pharmacy benefit managers in the country. Caremark, Express Scripts, and Optum Rx together control about 80% of all prescription drug claims in the United States. Caremark alone processes more than 2 billion prescription claims every year. When Caremark makes a formulary decision, meaning which drugs they cover and which they do not, it shapes access for tens of millions of Americans, not just Aetna members.
The third is the retail pharmacy, the stores that you and I can walk in that are on the corner in every town. They have about 9,000 CVS stores. That is where many of these prescriptions actually get filled. On May 1st, 2025, CVS Caremark announced that beginning July 1st, 2025, it would drop Zepbound from its preferred formulary and move Wegovy into the preferred position for obesity treatment. That was not a Medicare decision. That was the commercial formulary that covers employer-sponsored plans. Roughly 200,000 patients who had been on Zepbound were affected. If you were one of those 200,000 patients, you got a letter telling you the medication that was working for you was no longer going to be covered, and you had to switch. That is not a small thing when you've been fighting this disease your entire life. Many of them were forced to switch to Wegovy whether they wanted to or not. Others went through appeals. Some lost coverage altogether. CVS's own data says more than 95% of weight loss utilization on their commercial book of business is now on the preferred product, meaning Wegovy. They project 500 to 600 million dollars in savings. From their perspective, the strategy is working. From the patient perspective, a lot of people had their treatment changed by a formulary decision, not by their doctor. That decision is already the subject of a lawsuit. CNN reported in September of last year that a class action had been filed over the Zepbound removal. Patients and providers submitted dozens of letters documenting that Zepbound was the medication that worked for them. CVS's position is that Wegovy and Zepbound are clinically similar, and that forcing the manufacturers to compete on price ultimately broadens access.
Now, I'm not going to relitigate that debate right now. What I will tell you is that CVS has a track record of making aggressive cost decisions in the GLP-1 space. And that track record is the context for what happened this week. That track record is the record that puts profits in front of patients. When CVS told Bloomberg they would not participate in the Medicare balance program, that was not a surprise coming out of nowhere. It was the next move by a company that has been signaling for a year that the economics of broad GLP-1 coverage do not work for them at current prices. Even at the $245 net price CMS negotiated, even with the federal government sharing the risk, even with millions of Aetna Medicare patients potentially eligible, CVS looked at the math and said, "Nope. I don't think so." These are companies that make decisions lightly. They have more data on GLP-1 use than almost anyone else in the country. Because Caremark fills so many of these prescriptions, they know exactly what these medications cost, who is taking them, and for how long. If they're saying the balance structure does not work, regulators and the other insurance companies are paying attention.
Now, let me spend a minute on United Healthcare because their position is not the same as CVS's, and that difference matters. United Health Group is the largest health insurance company in the country. Their Medicare Advantage business covers more seniors than any other private insurer. They also own Optum Rx, which is another one of the big three pharmacy benefit managers, sitting right next to Caremark and Express Scripts in the companies that processed almost all the prescription drug claims in the country. In total, Optum Rx covers more than 60 million people. When United Health speaks on a Medicare policy question, regulators and the industry listen as well. They are that big. And here's what is interesting about their position. CVS said no, emphatically, full stop. We're not going to do it. United Health did not say no. They said, and I'm quoting again, "Notable changes and outstanding questions with the currently planned structure." They said they are still working through the process internally. They said they want to find a path to coverage over time. That's a hedge, not a refusal, and the difference tells you something about where this story is going next.
United Health has historically been less aggressive than CVS in the GLP-1 space. When CVS Caremark dropped Zepbound from its preferred formulary last July, Optum Rx kept Zepbound on its formulary. It meant patients with United Health commercial plans generally kept access to the medication their doctor originally chose. All patients on CVS plans were forced to switch. United Health's chief medical officer, Dr. Rhonda Randall, has publicly told employers to slow down on making GLP-1 decisions and to consider what she called a whole person approach. They have been more cautious, but they have also been more patient. So, when Bobby Hunter says there are notable challenges with the balance structure, that is coming from a company that has been watching this space carefully, that has not made the same aggressive cost move CVS has, and that is signaling they want to find a way to yes, but not on these terms.
Wall Street is split on how to read it. Some analysts see this as a serious problem for Eli Lilly and Novo Nordisk with real revenue at stake. Others see United Health's comments as, quote, "More reflective of a negotiating posture than an outright refusal." That tension matters less for patients than it does for investors, but it tells you that smart observers cannot agree on whether balance is effectively dead or just being renegotiated. Think about it from CMS's perspective. They just lost CVS entirely. If they also lost United Health, balance is, as a concept, probably dead. But United Health has not walked away. They're still at the table. They're still talking, which means whatever CMS does next, whether it is a restructured balance, a different payment mechanism, or some third party we have not heard about yet, United Health's concerns are going to shape it.
Now, if you're a patient trying to read the tea leaves, Lord knows we all are, United Health's position is actually more useful to watch than CVS's. CVS's no tells you the current structure's broken. United Health's maybe tells you what it would take to fix it. Between CVS and United Health, you get two halves of the same story. CVS tells you why the current plan failed. United Health tells you what the next plan has to solve for. That's a bigger signal than one insurance company declining one government program.
So, on Tuesday afternoon at 4:39 p.m. Eastern, CMS sent an email to Part D plan sponsors through the health plan management system. It was subsequently shared publicly on LinkedIn by Mark Newsom, president and founder of Health Evaluations. That email is the official CMS communication on what happened this week, and it's worth reading carefully because the language matters. The subject line was, quote, "Status update on the Bridge demo in the balance model in Part D for calendar year 2027." The first sentence reads, quote, "The Centers for Medicare and Medicaid Services is extending the Medicare GLP-1 Bridge through December 31st, 2027." CMS will delay implementation of the Medicare Part D portion of balance for calendar year 2027 pending further evaluation and data collection. Pay attention to that phrase, "Pending further evaluation and data collection." That is CMS language for we're not killing it, though we're not sure when or if it comes back.
The email goes on to say, and I'm quoting again, "CMS received feedback from Part D sponsors that an extension of the Medicare GLP-1 Bridge would offer a valuable opportunity to provide plans with additional data and facilitate a smoother transition to the potential implementation of balance in Part D." That sentence is important for two reasons. First, CMS is publicly acknowledging that insurance companies pushed back. The phrase CMS received feedback from Part D sponsors is the diplomatic version of insurers said no, and we listened. Second, notice the word potential CMS used to describe balance in Part D as a program that would launch in 2027. As of this email, CMS is now describing it as a potential implementation. That's a meaningful downgrade in CMS's own language. A program that will launch and a program that might launch are not the same thing.
CMS also told Part D sponsors to, quote, "Not indicate participation in the balance model within the health plan management system nor the bid pricing tool for calendar year 2027." That means CMS is telling insurers to stop preparing for balance for next year. It is off the table for 2027.
One important detail, the Medicaid side of balance is still alive. The email confirms that CMS will still accept applications from state Medicaid agencies through July 31st, 2026. States can start participating anytime between May 1st, 2026 and January 1st, 2027. So, if you're on Medicaid in a participating state, balance is still coming. It is only the Medicare Part D launch that has been pulled back. Medicaid includes far more than the unemployed. Nearly two-thirds of adult enrollees are working, and about 40% of all US children receive coverage through Medicaid or Children's Health Insurance Program. Eligibility is based on income and life circumstances, covering families, pregnant women, seniors, and people with disabilities. In many states, low-income adults can qualify based on income alone, even while working full-time.
One thing on how the bridge itself is going to operate, CMS chose to plug the bridge into existing Medicare infrastructure rather than build a new system from scratch. Humana's Linet program already processes claims for low-income Medicare beneficiaries every day, which gave CMS a running system to build on. That is an operational decision, not an endorsement of any one company, and patients will still need to navigate whatever prior authorization process Humana applies. But from a purely logistic standpoint, standing up the bridge on an existing platform is less risky than launching something brand new by July 1st. The bridge is still starting July 1st, 2026. You were originally going to get 6 months of bridge access before the program handed off to your Part D plan under balance. Now, you're going to get 18 months of bridge access instead. That is longer than what was originally announced. If you qualify, you will pay $50 a month for Wegovy or Zepbound from July 2026 through December 2027. That coverage runs through the federal government through Humana as the central processor, and it does not depend on which Part D plan you are enrolled in or whether any insurance company signed up to balance.
So, here's a quick summary of who qualifies, though I covered this in much more depth in the prior video linked below. You need to be 18 or older and enrolled in a Medicare Part D plan, either stand-alone or through Medicare Advantage. You qualify if you have a BMI of 35 or higher or a BMI of 30 or higher with certain cardiovascular or kidney conditions, or a BMI of 27 or higher with conditions like prediabetes, a prior heart attack, a prior stroke, or peripheral artery disease. Your provider submits the prior authorization to Humana. If you qualify, you pay $50 bucks a month at the pharmacy. The price the drug makers are accepting is $245 per month supply. You pay $50 of that. The federal government pays the rest. For the full detail, including exactly which versions of these conditions qualify and what your doctor needs to document, go to the linked video.
So, here's the question that is now unresolved. What happens on January 1st, 2026? Balance in Medicare Part D was supposed to be the answer. It's not launching on schedule, and CMS is now describing it as a potential implementation rather than a confirmed one. CMS has bought itself a year through the end of 2027 to either restructure the program, collect more data, or find a way to bring more insurance companies on board. If they cannot, Medicare beneficiaries who got access through the bridge could lose it at the end of 2027. It's been pushed down the road. It has not been solved.
This is the second time in roughly 18 months that a Medicare GLP-1 coverage plan has run into serious implementation trouble. A proposal under the previous administration was pulled back. This administration structure has now been restructured. Different approaches, same wall. That tells you something about how hard this actually is, regardless of who's in charge. About 48% of Medicare beneficiaries have obesity. Covering GLP-1s for that population is expensive, and insurance companies are telling the federal government they will not absorb that cost inside Part D premiums without a different structure. The federal government is now absorbing it directly through 2027. What happens after that is going to depend on negotiation, on pricing, and on whether the industry can come to a workable arrangement.
So, let me give you an action plan based on where we are today. If you're on Medicare right now, talk to your doctor between now and June. The bridge opens July 1st, 2026. That's about 10 weeks away. You want to have the clinical criteria before the program. And what I would tell you is don't make assumptions. Talk to your doctor. Pull your records. Know your BMI. Know your qualifying conditions. If you're on the edge of eligibility, know what you need to document. Heart failure with preserved ejection fraction, uncontrolled blood pressure, chronic kidney disease, pre-diabetes, a previous heart attack, a previous stroke, peripheral artery disease. If any of those apply, make sure they are clearly in your medical record and your doctor is aware of them. Come July 1st, prior authorizations are going to flood Humana as the central processor. Patients who get in first are the patients whose doctors already have the paperwork ready. Don't wait.
If you're approaching Medicare age, so if you're turning 65 in the next 12 to 18 months, this matters to you right now because you're going to be making Part D plan choices during open enrollment this October. Open enrollment runs from October 15th through December 7th every year. The plan you pick for 2027 will be the plan you have when the bridge is running and potentially when Balance or whatever replaces it launches. Who knows what ends up happening, so it's going to be really difficult. Do the best you can. The bridge does not care which Part D plan you are on. You just need to be enrolled in one. But if Balance or a successor program does launch in 2028, your plan choice could matter a lot. Keep watching this space. We will cover open enrollment specifically as we get closer to October.
If you are helping a parent or family member navigate this, start the conversation early. A lot of Medicare beneficiaries do not know this program exists. They do not know about the bridge. They do not know about Balance. They certainly do not know what happened this week. If you're the adult child helping a parent think through their medications, you may be the one who brings this to their attention. Have the conversation with them. Help them pull their records. Help them talk to their doctor. If there is a prior authorization to file, help them through the process. This is where advocacy inside a family actually matters.
If you're not on Medicare, but you follow this industry, what happened this week is a signal. The biggest insurance companies in the country just told the federal government they will not absorb GLP-1 coverage inside their existing Part D premiums without a different structure. That has implications beyond Medicare. It tells you something about how commercial coverage is going to evolve. It tells you something about how employer plans are going to approach these medications going forward. And it tells you that the pricing conversation, the one about whether these drugs are sustainable at current list prices, is not over. It's just beginning. If you're paying out of pocket right now like Lorraine and I have been, none of this changes your immediate situation. But the long-term cost conversation is moving, and that conversation eventually shapes what you pay, too.
For everyone, all of you out there, watch what CMS announces next. They're going to have to decide whether to restructure Balance, push it back further, or find another way to keep the coverage going. When that decision comes, we will cover it. If you have questions about your specific situation, talk to your doctor. Talk to a licensed Medicare advisor. And drop your questions in the comments below. As you know, I read all comments, and I will frequently answer your questions. And we love to use your questions as things for future videos to cover.
So, what we know as of today, just to recap, this is where things stand as I finished recording. The CMS email confirming extension and delay is public. CVS's decision is confirmed. The United Health position is confirmed. The reporting is being carried by Bloomberg, Axios, STAT News, MarketWatch, and CNBC. And as of this recording, the official CMS Bridge and Balance pages have not yet been updated to reflect Tuesday's announcement. But that's a matter of web updates, not a question about the policy changes. The policy changes confirmed by the CMS email itself. The story is moving fast. Things may change between the time we hit record and the time you're watching this. A major insurance company could change its position. CMS could announce a restructured program. A drug company could make a new pricing move. Any of those would shift the picture again. What we are telling you this morning is what we know right now, sourced to the CMS email, the reporting from Axios, STAT, Bloomberg, and CNBC, and the public earning statements from United Health. We will keep watching. We will keep reporting. We'll keep making videos. And when this changes, and it will change, we'll bring you the next update.
If this was helpful, the single best thing you can do is subscribe because this story is going to have three, four, maybe 20 updates before summer. And I do not want you finding out about the next one 6 weeks late. If you haven't already, take a moment to like and subscribe. And tell me what you think of this constantly changing landscape. My name is Christopher Durham, and we are not sized.