CMS published plans Dec. 23 for its voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth” — or BALANCE — model.
The announcement comes weeks following the White House’s agreements with Eli Lilly and Novo Nordisk to apply most-favored-nation pricing for drugs that treat obesity, diabetes and related conditions.
“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,” CMS Administrator Mehmet Oz, MD, said in a news release.
Here are seven notes on the model:
1. CMS will negotiate reduced prices with GLP-1 manufacturers for state Medicaid programs and Medicare Part D plans. Eligible manufacturers must have a product that is any combination of GIP, GLP‐1 and glucagon receptor agonist with an FDA-approved active ingredient for weight management. The drug must be proven to reduce body weight by at least 10% on average.
2. The model will also supplement with “lifestyle support programs” at no cost, such as by encouraging beneficiaries to embrace lower-calorie diets and increased physical activity.
3. Part D sponsors are eligible to participate in the model, along with any states in the Medicaid drug rebate program.
4. Weight-loss coverage will begin in May 2026 for Medicaid and January 2027 for Medicare Part D. A bridge program will enable GLP-1 access for Medicare Part D by July 2026.
5. Those who already qualify for a GLP-1 may be able to access that drug at a reduced price through the model.
6. Interested participants should respond to CMS by Jan. 8, 2026.
7. The Alliance of Community Health Plans released a statement on the initiative. “Research has raised concern about side effects, risks and adherence,” the group said. Still, it said, “We appreciate the administration’s commitment to this approach in the aptly named, voluntary BALANCE coverage model for GLP-1s in Medicare and Medicaid. We are eager to see additional details, including the cost to health plans.”
