News: Anti-obesity medication included in CY 2026 Medicare Part D proposed rule

CMS has issued a proposed rule containing modifications to the Medicare Advantage (MA) program, the Medicare prescription drug benefit program (“Part D”), as well as the Medicare cost plan program, according to a federal press release.

According to a CMS fact sheet, the stated intent of the calendar year (CY) 2026 proposal is to “to hold MA and Part D plans more accountable for delivering high-quality coverage so that people with Medicare are connected to the care they need when they need it.”

“This proposed rule,” the statement read,

includes more policies to remove unnecessary barriers to care stemming from the use of inappropriate prior authorization by clarifying requirements for plan use of internal coverage criteria and proposing guardrails for the use of artificial intelligence (AI) to protect access to health services. It would also expand access to transformative anti-obesity medications under the Medicare Part D and Medicaid programs, helping to ensure more Americans have access to these medications.

For instance, one noteworthy and potentially contentious modification concerns the coverage of anti-obesity medication. Prior to this proposed rule, CMS had not considered obesity to fall under the category of “a disease,” in particular, a “chronic disease.” As a result, anti-obesity medications were largely excluded from Part D coverage.

In light of the new proposed rule, however, “CMS now proposes to […] permit coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to reduce excess body weight and maintain weight reduction long-term for individuals with obesity.”

The proposed rule also addresses other subjects, such as: format provider directories for the Medicare Plan Finder; ensuring equitable access to behavioral health benefits through section 1876 cost plan and MA cost sharing limits; and promoting informed choice through agent and broker requirements on programs to help beneficiaries and enhanced review of marketing and communications (among others).

Editor’s note: To read the CMS fact sheet, click here. To read the proposed rule itself, click here.