CMS Launches BALANCE Model to Improve Access and Reduce Costs for GLP-1 Medications

The Centers for Medicare & Medicaid Services (CMS) announced on December 23 a new voluntary test of a model designed to enable Medicare Part D plans and state Medicaid agencies to cover GLP-1 medications for weight management and metabolic health, while helping to control costs for patients and taxpayers.

In a news release, CMS explained that the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) Model builds on evidence that combining access to GLP-1 medications with evidence-based lifestyle supports improves long-term health outcomes.

Under the model, CMS negotiates directly with pharmaceutical manufacturers of GLP-1 drugs for lower net prices and standardized coverage terms. Negotiation areas include:

• Guaranteed net pricing and potential out-of-pocket limits for beneficiaries
• Standardized coverage criteria
• Evidence-based lifestyle support offerings

Participation will be voluntary for manufacturers, states, and plans. Additional information will be released in early 2026 regarding state and Part D plan participation. The BALANCE Model will launch in Medicaid as early as May 2026 and in Medicare Part D in January 2027.

CMS has issued a Request for Applications to manufacturers, due by January 8, 2026. Additionally, CMS has sent notices of intent to state Medicaid agencies and Medicare Part D plans, also due by January 8, 2026.

Before launching the BALANCE model, CMS also plans to introduce a new Medicare GLP-1 payment demonstration starting in July 2026, which will act as a short-term bridge to the model.

The GLP-1 payment demonstration will operate outside of the Medicare Part D benefit’s coverage and payment process, meaning that Part D Plan Sponsors will not bear risk for eligible GLP-1 products provided during the demonstration. Beneficiaries enrolled in Medicare Part D who meet the negotiated access criteria will be able to access these drugs. Under the demonstration, eligible Medicare beneficiaries will pay $50 for a month of GLP-1 medications.