Breaking News: CMS Pilot Program
The Centers for Medicare and Medicaid Services (CMS) is reportedly reconsidering coverage of GLP-1 drugs for weight management and obesity treatment, reviving a Biden-era proposal that the Trump administration previously eliminated. This potential policy shift could dramatically impact millions of Americans struggling with obesity and weight-related health conditions.
According to reports from The Washington Post, the proposed coverage program represents a significant departure from current Medicare and Medicaid policies that largely exclude anti-obesity medications from standard coverage plans.
Five-Year Voluntary Pilot Structure
The proposed pilot program would span five years and operate on a voluntary basis, allowing individual state Medicaid programs and Medicare Part D plans to opt into covering popular GLP-1 medications. This approach provides flexibility for states and insurance plans while gathering real-world data on the effectiveness and cost-impact of obesity drug coverage.
What the Proposed Coverage Includes
Covered Medications
The pilot program would potentially cover several breakthrough medications that have revolutionized obesity treatment:
- Novo Nordisk’s semaglutide brands: Ozempic and Wegovy
- Eli Lilly’s tirzepatide drugs: Mounjaro and Zepbound
These medications have demonstrated remarkable efficacy in clinical trials, with many patients achieving significant weight loss of 15-20% of their body weight.
Coverage Scope
According to CMS documents reviewed by The Washington Post, these drugs would be covered specifically for “weight management” purposes, marking a potential recognition of obesity as a legitimate medical condition requiring pharmaceutical intervention.
Policy Reversal Under New Administration
Biden Administration’s Original Proposal
The current consideration represents a return to policies initially proposed during the Biden administration. In November 2024, the previous administration’s CMS released a comprehensive proposal to include GLP-1 drugs under Medicare Part D coverage.
The original proposal aimed to “recognize obesity to be a chronic disease based on changes in medical consensus,” according to official fact sheets released at the time. This represented a significant shift in how federal healthcare programs viewed and treated obesity.
Trump Administration’s Course Correction
However, the policy landscape changed dramatically in April 2025 when CMS, under President Donald Trump’s administration, released a final ruling that excluded the obesity coverage proposal. The agency stated it was “not finalizing certain provisions from the proposed rule,” effectively removing obesity drug coverage from consideration.
Despite this decision, CMS maintained that the agency “may consider future policy options” for anti-obesity medications, leaving the door open for future coverage discussions.
Industry Response and Workarounds
Pharmaceutical Company Criticism
Eli Lilly expressed strong opposition to the Trump administration’s decision, stating in May 2025: “We don’t believe this is right.” The company argued that removing obesity coverage made access “more difficult” for patients already struggling to obtain these medications.
Creative Coverage Solutions
Both major manufacturers have developed innovative strategies to circumvent coverage limitations:
Eli Lilly’s Approach:
- Added sleep apnea as an additional indication for Zepbound
- Received approval in December 2024
- Secured CMS coverage within weeks
Novo Nordisk’s Strategy:
- Obtained Medicare coverage for Wegovy in March 2024
- Focused on cardiovascular risk reduction in patients with preexisting heart disease
- Successfully positioned the drug as preventive cardiovascular therapy
Impact on Patients and Healthcare System
Patient Access Challenges
The inconsistent coverage policies have created significant barriers for patients seeking obesity treatment. Many individuals face:
- High out-of-pocket costs often exceeding $1,000 monthly
- Limited insurance coverage options
- Difficulty accessing prescribed medications
Potential Cost-Benefit Analysis
Former CMS administrator Chiquita Brooks-LaSure described the proposed program as a potential “game changer” for patients, particularly if it leads to broader coverage changes across the healthcare system.
Future Implications
The pilot program, if implemented, could provide crucial data on:
- Long-term health outcomes for patients with covered GLP-1 access
- Cost-effectiveness of obesity treatment versus complications
- Healthcare utilization patterns in covered versus non-covered populations
This data could inform future permanent coverage decisions and potentially influence private insurance policies nationwide.
Next Steps
While CMS has not officially confirmed the pilot program, the agency’s spokesperson emphasized that “all drug coverages undergo a cost-benefit review.” The final decision will likely depend on comprehensive analysis of fiscal impacts on state Medicaid agencies and overall healthcare costs.
The potential coverage expansion represents a critical juncture in American obesity treatment policy, with implications extending far beyond individual patient access to fundamental questions about healthcare priorities and resource allocation.
Discover the latest GovHealth news updates with a single click. Follow DistilINFO GovHealth and stay ahead with updates. Join our community today!
