12/31/2025
We have alot of clients asking about GLP-1 acess... keeping you up-to-date:
The Trump administration has unveiled yet another new payment model, this one focused on the cost of GLP-1 therapies.
The Centers for Medicare & Medicaid Services (CMS) on Tuesday announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth, or BALANCE, model. The program seeks to make it easier for Medicare Part D plans and Medicaid programs to offer coverage for GLP-1s, while managing the cost to patients and taxpayers.
Under the model, the CMS will negotiate with the manufacturers of these drugs to secure lower net prices and standard coverage terms. The agency said in an announcement that as part of the negotiations, the parties could discuss out-of-pocket limits for patients, coverage criteria and evidence-based lifestyle supports.
The model is voluntary for state programs, Part D insurers and drugmakers, according to the announcement. The CMS said it will release additional details on participation in early 2026.
The agency plans to launch BALANCE in Medicaid as early as May 2026 and in January 2027 for Part D. The CMS said it will launch a short-term GLP-1 payment model in July 2026 that it says “will serve as a short-term bridge to the model,” allowing beneficiaries to access lowest costs for these drugs before the model fully launches.
The CMS has opened a request for applications to drug manufacturers and will accept responses through Jan. 8. Notices of intent for state Medicaid agencies and Part D plans are also due on Jan. 8, the CMS said.
The Center for Medicare and Medicaid Innovation (CMMI) will closely track the model’s impact on cost, outcomes and adherence to determine whether it’s working to improve health and lower costs, per the announcement.
“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, such as diabetes, cardiovascular disease, and other metabolic conditions, which can negatively affect a person’s long-term health,” CMMI Director Abe Sutton said in the press release. “Through this model, CMS will make GLP-1s more accessible for people with Medicare and Medicaid.”
