The Centers for Medicare & Medicaid Services (CMS) has introduced a new voluntary model aimed at enabling Medicare Part D plans and state Medicaid agencies to cover GLP-1 medications. These drugs are used for weight management and improving metabolic health, with the goal of controlling costs for patients and taxpayers. The initiative, named the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model, seeks to combine access to these medications with lifestyle support to enhance long-term health outcomes.
CMS Administrator Dr. Mehmet Oz said, "Today’s announcement builds upon our historic Most Favored Nations drug pricing deals’ goal of democratizing access to weight-loss medication, which has been out of reach for so many in need." He added that the BALANCE Model aims to merge scientific advancements with healthy living practices to reduce costs while empowering individuals in managing their health.
The model involves CMS negotiating directly with pharmaceutical manufacturers for lower prices and standardized coverage terms. It will address guaranteed net pricing, potential out-of-pocket limits, standardized coverage criteria, and evidence-based lifestyle support offerings. Abe Sutton, Director of the CMS Innovation Center, commented on the initiative's potential impact: "The BALANCE Model will empower more Americans to live healthier lives by expanding access to GLP-1s that have shown to be a powerful tool against the development of diseases."
Participation in this model is voluntary for manufacturers, states, and plans. Further details about participation will be available in early 2026. The model is set to launch in Medicaid by May 2026 and in Medicare Part D by January 2027. A Request for Applications from manufacturers is due by January 8, 2026.
Additionally, CMS plans a new Medicare GLP-1 payment demonstration starting July 2026 as a precursor to the BALANCE Model. This demonstration allows Medicare beneficiaries access to these medications at negotiated prices outside the standard Medicare Part D benefit's coverage flow.
For more information on the BALANCE Model: https://www.cms.gov/priorities/innovation/innovation-models/balance
