CMS Launches BALANCE Model to Expand GLP-1 Coverage in US
Key Summary
- The Centers for Medicare & Medicaid Services (CMS) announced the voluntary Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model to enable Medicare Part D plans and state Medicaid agencies to cover GLP-1 medications for weight management and metabolic health while controlling costs.
- The model pairs GLP-1 access with evidence-based lifestyle supports, aiming to improve long-term outcomes and affordability for beneficiaries and taxpayers.
- A $50 monthly Medicare GLP-1 payment demonstration will begin in July 2026 as a bridge ahead of the model’s phased launch.
CMS has unveiled a new voluntary payment and coverage test designed to expand access to GLP-1 medications for weight management and metabolic health. Announced by CMS, the (BALANCE) Model targets Medicare Part D and Medicaid, with a focus on affordability, standardized coverage, and lifestyle support integration.
The BALANCE Model builds on emerging evidence that combining GLP-1 medications with evidence-based lifestyle supports can improve long-term health outcomes. Under the model, CMS will negotiate directly with pharmaceutical manufacturers to establish lower net prices and standardized coverage terms for GLP-1 drugs.
Negotiation areas include guaranteed net pricing with potential out-of-pocket limits for beneficiaries, standardized coverage criteria, and required evidence-based lifestyle support offerings. Participation will be voluntary for manufacturers, state Medicaid agencies, and Medicare Part D plans.
The CMS Innovation Center will evaluate the model’s effects on costs, medication adherence, clinical outcomes, and beneficiary experience to determine whether it improves health and generates savings. CMS has issued a Request for Applications to manufacturers, along with notices of intent for states and Part D plans. All applications and notices are due January 8, 2026.
Clinical Implications
If implemented as designed, the BALANCE Model could materially change access to GLP-1 therapies for Medicare and Medicaid populations in the US. GLP-1 medications have been shown to address metabolic conditions associated with diabetes and cardiovascular disease, but coverage and affordability have limited uptake among publicly insured patients.
By standardizing coverage criteria and pairing drug access with lifestyle interventions, CMS aims to support sustained health improvements rather than short-term weight loss alone. For health system leaders and payers, the model signals a shift toward integrated benefit design that links pharmaceutical coverage to supportive services.
The voluntary structure also allows states, plans, and manufacturers to assess financial and operational implications before participating. CMS’s planned evaluation will be central to determining whether negotiated pricing and structured supports can balance expanded access with fiscal responsibility.
Conclusion
CMS plans to launch the BALANCE Model in Medicaid as early as May 2026 and in Medicare Part D in January 2027. A separate Medicare GLP-1 payment demonstration beginning July 2026 will provide earlier access at a negotiated $50 monthly cost, serving as a bridge to the full model rollout.
Reference
Centers for Medicare & Medicaid Services. CMS launches voluntary model to expand access to life-changing medicines, promote healthier living. CMS.gov. December 23, 2025. Accessed January 13, 2026. https://www.cms.gov/newsroom/press-releases/cms-launches-voluntary-model-expand-access-life-changing-medicines-promote-healthier-living
